- 

l/jf%Wf 


JMMM^' 


Southern  Subscription  Igencr.) 
W.  B.  DALSTON. 

Medical  Books. 

17  ft  19  E.  Alabama  St., 

ATLANTA,  GA. 


II  IN     81971 

IRVINE.  CALIFORNIA  92664 


THE 


VENEBEAL  DISEASES 


INCLUDING 


STRICTURE  OF  THE  MALE  URETHRA 


BY 


E.  L.  KEYES,  A.M.,  M.D., 

PBOFESSOB  OP  DEBMATOLOGY  AND  ADJUNCT  PBOFESSOB  OP  SUBGEBY  IN  THE  BELLEVTJE  HOSPITAL 

MEDICAL  COLLEGE  ;  ONE  OF  THE  SUBGEONS  OF  BELLEVUE  HOSPITAL  ;  CONSULTING 

SURGEON  TO  THE  CHABITY  HOSPITAL,  ETC.,  ETC. 


NEW  YORK: 

WILLIAM    WOOD    &   COMPANY 

27  GKEAT  JONES  STKEET 

1880 


OOPYBIQHT,   1880,  BY 

WILLIAM   WOOD  &  COMPANY. 


Tuow's 

PRINTING  AND  BOOKBINDING  COMPANY, 

201-213  East  i2tA  Street, 

NEW  YORK. 


PROFESSOR  WILLIAM   H.  VAN  BUREN, 

IS     GRATEFUL     ACKNOWLEDGMENT     OP 

MUCH     VALUABLE     COUNSEL 

AND 

IN    REMEMBRANCE    OP    MANY   TEARS    OP    PROFESSIONAL   ASSOCIATION, 

THIS     BOOK 

Snscribeb 

BY    THE    AUTHOR 


I/ 


PREFACE. 


THIS  volume  is  designed  by  the  publishers  to  be  one  of  a  series 
addressed  to  the  general  medical  practitioner.  My  aim  has,  therefore, 
been  to  present  the  various  venereal  diseases  as  clearly  as  possible, 
avoiding  such  unnecessary  refinement  npon  theoretical  and  mooted 
points  as  would  be  apt  to  lead  to  confusion  or  to  error. 

Practical-  utility,  as  well  as  what  I  believe  to  be  sound  doctrine,  has 
been  kept  constantly  in  view,  and  no  effort  has  been  made  to  display  a 
long  list  of  remedies.  Such  means  as  I  have  found  most  valuable  are 
recorded,  together  with  suggestions  from  well-recognized  authorities. 
A  physician  cannot  afford  to  have  many  remedies  for  a  given  disease 
if  he  expects  to  use  any  of  them  well. 

My  views  on  many  of  the  subjects  included  in  this  volume,  are 
already  before  the  public,  scattered  through  various  books  and  essays. 
In  the  main  these  views  are  unchanged.  Such  alterations  as  time  and 
a  larger  experience  have  effected  are  recorded  herein.  My  ideas  on  the 
treatment  of  syphilis  are  only  modified  in  that  the  tonic  dose  of  the 
specific  is  made  rather  smaller,  and  the  course  rather  longer  than 
formerly. 

I  have  opposed  the  views  of  those  gentlemen  who  are  throwing  con- . 
fusion  in  the  way  of  the  general  practitioner  by  trying  to  break  down 
the  distinctions  between  the  initial  lesion  of  true  syphilis,  and  chancroid; 
and  who  teach  that  chancroid  may  be  derived  from  the  products  of  the 
syphilitic  early  or  late  lesions.  I  have  also  taken  issue  with  the  experi- 
menters who  claim  to  prevent  syphilis  by  excising  the  initial  lesion,  on 
the  ground  that  something  more  than  induration  in  a  sore  is  necessary 
in  order  to  prove  it  to  be  a  syphilitic  chancre.  Without  a  reliable  history 
showing  previous  freedom  from  syphilis  in  such  patients,  added  to  con- 
frontation, the  records  of  excised  chancres  fail  to  be  convincing,  and 
the  moderate  percentage  of  claimed  success  is,  thus  far,  not  proven. 
It  is  to  be  hoped  that  some  good  will  eventually  come  of  these  exper- 
iments, but  more  accuracy  of  observation  must  be  brought  to  the  inves- 
tigation than  has  been  yet  employed. 

Finally,  I  have  raised  my  voice,  for  what  it  may  be  worth,  in  protest 

6  6"?  3 


VI  PREFACE. 

against  the  views  of  the  new  school  in  urethral  pathology,  which  seems 
to  claim  that  every  natural  undulation  in  the  tissues  of  the  pendulous 
urethra  is  a  stricture  fit  for  cutting,  and  that  all  the  ills  of  the  genito- 
urinary passages  may  be  accounted  for  by  the  existence  of  these  undu- 
lations, and,  usually,  made  to  disappear  when  the  latter  are  cut. 

To  the  honest  labor  and  mechanical  genius  of  the  leader  of  this 
school  I  tender  my  respect.  The  profession  is  indebted  to  him  for 
some  capital  instruments  and  for  a  broader  understanding  of  the  toler- 
ance and  of  the  possible  capacity  of  the  urethra  than  it  has  yet  pos- 
sessed. 

The  profession  as  a  whole  doubtless  still  underrates  the  normal 
capacity  of  the  male  urethra,  and  after  the  present  rage  for  cutting  has 
passed  and  the  reaction  has  come,  a  calm  equilibrium  will  finally  es- 
tablish itself,  which,  on  the  whole,  will  be  to  the  advantage  of  those 
patients  who  in  time  to  come  may  suffer  with  urethral  difficulties. 

The  theories  of  the  new  school  are  as  ingeniously  perfect  as  the 
instruments  which  carry  them  out ;  but,  unfortunately,  its  claims  seem 
to  leave  out  of  view  that  the  disease  for  which  the  patient  seeks  relief 
is  only  a  symptom,  and  that  such  symptom  may  be  due  to  a  variety  of 
causes.  What  will  cure  the  symptom  in  one  case  will  not  necesarily  do 
so  in  another.  And  a  serious  criticism  upon  the  methods  of  the  new 
school  is  that  it  does  not  generally,  in  its  lists  of  published  cases,  give 
any  prominence  to  those  cases  which  have  been  cut  without  relief  of 
the  symptoms  complained  of. 

In  short,  the  pathology  and  the  treatment  of  the  new  school  are 
narrow,  and  tend  to  encourage  routine  practice  in  the  young,  to  the 
detriment  of  a  careful  study  of  each  case. 

Thanks  are  due  to  Dr.  G.  H.  Fox,  of  New  York,  for  the  admirable 
photographs  from  nature  after  which  many  of  the  woodcuts  illustrat- 
ing venereal  lesions  have  been  made.  Syphilitic  lesions  cannot  be  per- 
fectly represented  without  the  use  of  color,  but  I  think  that  the  exhibi- 
tion of  the  topography  of  the  different  eruptions  is  in  itself  enough  to 
justify  the  use  of  woodcuts. 

E.  L.  KEYES. 
NEW  YORK,  Jan.  1,  1880. 

No.  1  Park  Avenue, 
Corner  of  Thirty-fourth  Street  East. 


CONTENTS. 


PART  I. 
CHAPTER  I. 

CHANCROID. — THE  NON-SYPHILITIC  VENEREAL  TTLCEB. 

PAGE 

Chancroid. — Definition. — General  Description  of  Typical  Clinical  Chancroid. — 
The  Nature  of  the  Chancroidal  Poison. — Answers  to  the  Objections  made  to 
the  Existence  of  any  Special  Chancroidal  Virus,  and  Discussion  of  the  Alleged 
Cases  of  Chancroid  purporting  to  have  been  produced  by  the  Inoculation  of 
Pus  not  derived  from  a  Chancroid. — Is  the  Poison  of  Chancroid  a  Modified 
Syphilitic  Virus  ?— Unity  and  Duality  in  Syphilis. — Twelve  Propositions  set- 
ting forth  Facts  relative  to  the  Question  of  Duality,  and  believed  to  be  sus- 
tained by  Facts,  Experimental  and  Clinical,  now  before  the  Profession.  1 

CHAPTER  II. 

CHANCROID.— DESCRIPTION  OP   ITS  SPECIAL  FEATURES  AND  OF  THE  VARI- 
ATIONS TO  WHICH  THEY  ARE  LIABLE. 

Pathological  Histology  of  Chancroid  ;  Comparative  Histology  of  Syphilitic  Chancre 
and  of  Chancroid. — Transmission  of  Chancroid  to  Animals. — Transmission  of 
True  Syphilis  to  Animals. — The  Relative  Frequency  of  Chancroid. — The  Meth- 
ods of  Chaucroidal  Contagion,  Direct  and  Mediate. — The  Inoculation  of  Chan- 
croid.— Auto-inoculation  and  Hetero-inoculation. — Case  illustrating  the  Diag- 
nostic Value  of  Auto-inoculation. — Inoculation  in  Generations. — How  to  Prac- 
tise Experimental  Inoculation.  — The  Incubation  of  Chancroid  ;  Variation  in 
Incubation. — Course  of  Chancroid;  Period  of  Increase;  Stationary  Period; 
Period  of  Repair  ;  Variations  in  Course. — Situation  of  Chancroid;  Variation 
in  Situation. — Number  of  Chancroids. — Form  of  Chancroid;  Variations  in 
Form. — Follicular  Chancroid. — Subjective  Symptoms  of  Chancroid. — Condi- 
tion of  the  Base. — Duration  of  Chancroid ;  Variations  in  Duration. — Cica- 
trix  of  Chancroid.  .  .  ....  15 


CHAPTER  III. 

CHANCROID. — DIAGNOSIS,   PROGNOSIS,   AND  TREATMENT. 

Diagnosis. — Diagnostic  Table  of  Chancre,  Chancroid,  and  Herpes. — Ulcerated  Non- 
virulent  Abrasions. — Different  Varieties  of  Pseudo-chancre  and  their  Treat- 
ment.— Six  Propositions  of  Importance  bearing  upon  the  Question  of  Auto- 


Vlll  CONTENTS. 

PIGS 

inoculation  for  Purposes  of  Diagnosis. — The  Prognosis  of  Chancroid. — The 
Treatment  of  Chancroid. — Prophylactic  Treatment. — Radical  Treatment. — 
The  Reason  why  Cauterization  will  not  always  arrest  a  Chancroid. — How  to 
cauterize  a  Chancroid. — Palliative  Treatment  of  Chancroid. — lodoform  and 
its  Use,  and  other  Topical  Applications. — Anal  and  Rectal  Chancroids. — Ure- 
thral  Chancroids. — Sub-preputial  Chancroids. — Chancroid  at  the  Margin  of 
the  Prepuce. — Chancroid  of  the  Vulva  and  Vagina. — Chancroid  of  the 
Fingers. 24 

CHAPTER  IV. 

CHANCKOID. — THE  COMPLICATIONS  OF  CHANCROID,  AND  THEIR  TREATMENT. 

Chancroid  complicated  by  Inflammation. — Inflammatory  Phymosis  and  Paraphy- 
mosis,  with  their  Treatment. — Phagedaena,  Sloughing  and  Serpiginous,  and 
its  Treatment. — Chancroid  complicated  by  Syphilis. — The  Lymphangitis  of 
Chancroid,  Inflammatory  and  Virulent,  and  its  Treatment. — The  Bubo  of 
Chancroid,  Simple,  Indolent,  Spontaneous  (Bubon  d'Emblee).  — Treatment  of 
Simple  Bubo. — Treatment  of  Indolent  Bubo. — Virulent  Bubo,  or  Subcuta- 
neous Chancroid. — Treatment  of  Virulent  Bubo.  .  37 


PART  II. 
CHAPTER  I. 

SYPHILIS. 

General  Considerations  upon  Syphilis. — Definition  of  Syphilis. — Effects  of  Climate 
upon  the  Disease. — Present  Mildness  as  compared  with  former  Virulence. — 
Outline  of  the  Course  of  Syphilis. — General  Pathology  of  Syphilis. — General 
Description  of  the  Pathology  of  the  various  Lesions  due  to  Syphilis,  and  the 
Lack  of  any  Specific  Quality  in  the  Elements  constituting  these  various 
Lesions 53 

CHAPTER  II. 

SYPHILia 

The  Poison  of  Syphilis :  is  it  a  Vegetable  Fungus  ? — The  Production  of  Syph- 
ilis in  Different  Animals.— The  Alleged  Antagonism  between  Syphilis  and 
Cancer. — Secretions  which  contain  the  Poison  of  Syphilis. — Peculiar  Viru- 
lence of  the  Secretion  of  Mucous  Patches. — Vaccinal  Syphilis. — Pathological 
Secretions. — Physiological  Secretions. — Infection  by  Milk ;  by  Semen. — Trans- 
mission of  Syphilis  by  Inheritance  through  the  Mother  alone ;  through  the 
Father  alone. — Date  at  which  a  Healthy  Pregnant  Woman  must  get  Syphilis 
in  order  to  Poison  her  Child.— Choc  en-retour.— Transmission  by  Inheritance 
to  the  Third  Generation. 61 

CHAPTER  III. 

SYPHILIS. 

Methods  of  Contagion  in  Acquired  Syphilis,  Direct  and  Mediate. — The  Duration 
of  Syphilis  and  the  Question  of  Marriage. — Cauterisatio  Provocatoria. — The 


CONTENTS.  IX 

PACK 

Prognosis  of  Syphilis,  and  the  Influence  of  Constitution  and  of  Intercurrent 
Physiological  and  Pathological  Conditions  upon  its  Course  and  Duration. — 
Second  Attack  of  True  Syphilis  occurring  in  Individuals  who  have  already 
once  had  Syphilis.  . 75 


CHAPTER  IV. 

SYPHILIS. 

The  Incubation  of  Syphilis. — Description  of  Syphilitic  Chancre :  the  Raw  Ero- 
sion, the  Superficial  Ulcer,  the  Herpetiform  Chancre,  the  Mixed  Chancre, 
Chancre  of  the  General  Integument,  Chancre  of  the  Lip,  of  the  Nipple,  of 
the  Urethra. — Syphilis  without  Chancre. — Typical  Course  of  Chancre. — Spe- 
cific Induration. — Complications  of  Chancre  by  Phagedaena. — Treatment  of 
Chancre  by  Excision  and  other  Means. — The  Lymphangitis  of  Chancre. — 
The  Bubo  of  Syphilis,  and  its  Treatment 85 


CHAPTER  V. 

SYPHILIS. 

A  Table  giving  a  Comprehensive  View  of  the  Features,  Course,  Symptoms,  etc. , 
of  Chancroid,  as  compared  with  Similar  Conditions,  when  met  with  in  con- 
nection with  Syphilitic  Chancre.  — The  Stages  of  Syphilis  :  Primary,  Secon- 
dary, Tertiary. — Malignant  Syphilis. — The  Second  Incubation. — Syphilitic 
Fever. — Symptoms  attending  the  Beginning  of  General  Syphilis.  .  .  .97 


CHAPTER  VI. 

THE  GENERAL  TREATMENT  OP  SYPHILIS. 

Syphilis  a  self  limiting  Malady. — It  gets  well  tinder  all  Treatments  sometimes, 
but  yields  the  best  Results  to  small  Doses  of  Mercury  continued  for  a  long 
Time. — Syphilization  and  Tartarization. — The  Hot  Springs  of  Arkansas. — 
Preventive  Treatment  of  Syphilis. — Excision  of  Syphilitic  Chancre. — The 
Hygienic  Treatment  of  Syphilis. — The  Hygiene  of  the  Mouth. — Hygiene  of 
the  Anus  and  of  the  Genitals. — Hygienic  Medication. — Kumyss. — Specific 
Treatment  of  Syphilis. — General  Consideration  of  the  Value  of  Mercury  and 
the  Different  Kinds  of  Mercurial  Treatment. — Salivation. — Time  at  which 
the  General  Treatment  of  Syphilis  should  be  commenced. — Detail  of  the 
Tonic  Treatment  of  Syphilis  by  Mercury. — The  Time  at  which  a  Tonic  Course 
of  the  Mercurial  Specific  may  be  stopped. 104 


CHAPTER   VII. 

THE  GENERAL  TREATMENT  OF  SYPHILIS — CONTINUED. 

Mercurial  Fumigation. — Simple  Method  of  taking  a  Bath  at  Home. — The  Inunc- 
tion of  Mercury. — Other  Methods  of  giving  Mercury. — The  Treatment  of  Sali- 
vation.— The  Local  Treatment  of  Syphilitic  Lesions  of  the  Integument;  of 
Mucous  Membranes. — The  Iodides  and  the  Preparations  of  Iodine. — The 
Evil  Effects  of  the  Iodides. — The  Dose  of  the  Iodides. — The  Mixed  Treat- 
ment.— When  to  cease  giving  the  Iodides. — Zittman'a  Decoction.  .  .  .  122 


X  CONTENTS. 

CHAPTER  VIII. 

SYPHILIS  OF  THE  SKIN. 

PAGE 

Special  Characters  of  the  Syphilidea :  Polymorphism,  Color,  Form,  Absence  of 
Subjective  Symptoms. — Characters  of  Scabs,  Ulcers,  Cicatrices  in  Syphilis. — 
The  Syphilides:  Erythematous,  Papular,  Pustular,  Ecthymatous,  Pigmen- 
tary, Vesicular,  Squamous  (Circinate,  Palmar  and  Plantar),  Tubercular  (Gen- 
eral, in  Groups). — Tertiary  Syphilides.—  Rupia.—  Tertiary  Pustular  Syphilide. 
— Ecthyma.— Pustular  Syphilide  in  Groups. — Tertiary  Syphilitic  Ulceration. 
— Gumma  of  the  Skin 142 


CHAPTER  IX. 

SYPHILIS  OP  MUCOUS  MEMBRANES. 

Erythematous,  Ulcerative,  Mucous,  and  Scaly  Patches,  and  Gummatous  Ulcers  of 

the  Mucous  Membranes  of  the  Mouth,  Nose,  and  Fauces.  .  .         .        .  165 

CHAPTER  X. 

SYPHILIS  OF  LYMPHATIC  GLANDS, — OF    HAIRY  PARTS,   OF  THE   FINGERS  AND   TOES, 
OF  MUSCLES,   TENDONS,   APONEUROSES,    BURS^E,   JOINTS,   BONES,    AND   CARTILAGE. 

Epitrochlear  and  Post-cervical  Indolent  Glandular  Engorgement. — Syphilitic  Alo- 
pecia.— Syphilitic  Onychia  and  Paronychia. — Dactylitis. — Syphilitic  Myostitis, 
Congestive,  Diffuse,  Gummatous. — Syphilis  of  Tendons,  Sheaths  of  Tendons, 
and  Aponeuroses. — Syphilis  of  the  Bursae. — Syphilis  of  Ligaments  and  Joints. 
— Syphilis  of  Bones. — Osteocopic  Pains. — Nodes,  Dry  Caries,  Gummy  Tumor 
of  Bone. — Mercury  as  a  Cause  of  Bone  Disease. — Syphilis  of  Cartilage.  .  .  171 

CHAPTER  XL 

SYPHILIS  OF  THE  RESPIRATORY  SYSTEM. — THE  DIGESTITE  TRACT,   ABDOMINAL 
GLANDULAR  ORGANS,   AND  THE  VASCULAR  SYSTEM. 

Syphilis  of  the  Nose.— Syphilis  of  the  Larynx;  non -Ulcerative —Ulcerative. — 
Syphilis  of  the  Trachea,  Bronchi,  and  Lungs. — Syphilis  of  the  Digestive 
Tract. — Gumma  of  the  Tongue. — Syphilis  of  the  (Esophagus. — Syphilis  of  the 
Stomach  and  Intestines. — Syphilitic  Stricture  of  the  Rectum. — Syphilis  of  the 
Peritoneum. — Syphilis  of  the  Pancreas. — Syphilis  of  the  Liver. — Diffuse  and 
Circumscribed  Hepatitis. — Gumma  of  the  Liver;  Amyloid  Degeneration. — 
Syphilis  of  the  Spleen. — Syphilis  of  theThymus,  of  the  Supra-renal  Capsules, 
and  the  Abdominal  Glands.— Syphilis  of  the  Heart. — Syphilis  of  the  Arteries, 
Veins,  and  Capillaries. 190 


CHAPTER  XII. 

SYPHILIS  OF  THE  NERVOUS   SYSTEM. 

General  Pathology  of  Nervous  Syphilis. — Syphilis  of  the  Brain,  Pachymeningitis, 
Gummata  of  the  Meninges,  Encephalitis,  White  Softening,  Gummata  of  the 
Brain. — Syphilis  of  the  Cerebral  Arteries. — General  Symptoms  of  Brain  Syphi- 
lis, Prognosis,  Treatment. — The  Special  Affections  produced  by  Syphilitic  Le- 
sions of  the  Brain. — Syphilitic  Hemiplegia,  Epilepsy,  Generalized  Paralysis, 


CONTENTS.  XI 

PAGE 

Catalepsy,  Chorea,  Aphasia,  Insanity. — Brain  Syphilis  simulating  Sunstroke 
often  followed  by  Desire  to  Sleep. — Syphilis  of  the  Cord. — Syphilitic  Para- 
plegia.— Syphilitic  Locomotor  Ataxia. — Syphilis  of  Special  Nerves,  of  Nerves 
of  Special  Sense,  and  Nerves  of  Motion.— Syphilis  of  the  Sympathetic.  .  .  205 


CHAPTER  XIII. 

SYPHILIS  OF  THE  GENITOURINARY   SYSTEM   IN  BOTH  SEXES. 

Syphilis  of  the  Kidney. — Syphilitic  Albuminuria. — Syphilis  of  the  Penis. — Syphi- 
lis of  the  Testicle  ;  Epididymitis,  Orchitis  (Diffuse,  Gummatous). — Diagnostic 
Table  of  Syphilitic,  Tubercular,  Cancerous,  and  Sarcomatous  Enlargement  of 
the  Testicle. — Treatment  of  Syphilis  of  the  Testicle. — Impotence  due  to 
Syphilis. — Syphilis  of  the  Genital  System  in  the  Female. — Functional  De- 
rangements of  Menstruation  due  to  Syphilis. — The  Effect  of  Syphilis  upon 
Pregnancy. — Cause  of  Abortion  in  Syphilis. — Syphilis  of  the  Mammary 
Gland,  Diffuse,  Parenchymatous,  Gummatous 219 

CHAPTER  XIV. 

SYPHILIS  OF  THE  EYE  AND  EAR. 

Syphilis  of  the  Eyelids  and  Conjunctiva. — Syphilis  of  the  Cornea,  the  Iris  (Plastic 
and  Gummatous  Iritis). — Syphilis  of  the  Vitreous,  of  the  Ciliary  Body,  of  the 
Choroid,  of  the  Retina  (Atrophy  of  the  Retina,  Retinitis  Pigmentosa). — 
Syphilitic  Optic  Neuritis. — Syphilis  of  the  Ear. — Syphilis  of  the  Outer  Ear 
and  Auditory  Canal. — Plastic  Myringitis. — Syphilis  of  the  Auditory  Nerve.' — 
Syphilis  of  the  Middle  Ear. — Ear  Affections  found  in  Inherited  Syphilis. — 
Catarrhal  Inflammation  of  the  Middle  Ear,  Deaf -mutism.  ....  235 

CHAPTER  XV. 

INHERITED  SYPHILIS. 

Syphilis  does  not  change  in  Type  during  Transmission  by  Inheritance. — The  Syphi- 
litic Foetus. — Bone  Syphilis  in  Inherited  Disease. — Inherited  Syphilis  in  the 
Infant. — Date  of  Appearance  of  Symptoms  in  Inherited  Disease. — Pemphigus 
of  Inherited  Syphilis. — The  Syphilitic  Countenance. — Syphilitic  and  Mercu- 
rial Teeth. — Interstitial  Keratitis. — General  Treatment  of  Inherited  Syphilis.  237 


PART  III. 

GONORRHOEA  AND  ITS  COMPLICATIONS. 
CHAPTER   I. 

GONOREHCEA  IN  THE  MALE. 

Definition. — True  Gonorrhoea  is  not  acquired  by  Contact  of  the  Urethra  with  Pua 
not  in  itself  Gonorrhoeal. — Cases  illustrating  that  Urethral  Pus  does  not  al- 
ways produce  Gonorrhoea  in  the  Female,  nor  Vaginal  Pus  in  the  Female 
always  Gonorrhoea  in  the  Male. — The  Causes  of  Urethral  Inflammation. — 
Symptoms  of  Urethritis  in  an  Unhealthy  Urethra  not  due  to  the  Contact  of  a 


Xll  CONTENTS. 

PAGE 

Virulent  Pus. — Symptoms  of  Inflammation  in  a  healthy  Urethra,  due  to  Con- 
tact of  Gonorrhceal  Pus  or  other  Irritating  Substance,  under  Circumstances 
capable  of  generating  Urethritis.—  Chordee. — Lymphangitis  of  the  Prepuce. 
— Spasmodic  Stricture. — Breaking  the  Chordee. — Gleet.  ....  249 


CHAPTER  II. 

TREATMENT  OF  URETHRAL  INFLAMMATION  IN  THE  MALE. 

The  Relation  of  the  Physician  to  his  Patient  during  the  Treatment  of  Urethritis. — 
The  Abortive  Treatment  of  Gonorrhoea. — Hygienic  Treatment ;  Medical  Treat- 
ment by  Alkaline  Diuretics,  by  Sandal- Wood  Oil,  by  Copaiba  (Copaibal  Ery- 
thema), by  Cubebs,  by  Turpentine,  by  Iron,  by  Tincture  of  Cantharides. — 
The  Internal  Treatment  of  Gleet. — The  Use  of  Injections  in  Urethritis. — 
How  to  Inject  the  Urethra. — Dressings  for  the  Penis  during  Urethritis. — 
Treatment  of  Chordee. — Treatment  of  Painful  Urination. — Treatment  of  Re- 
tention of  Urine  in  Gonorrhoea. — Treatment  of  Venereal  Warts. — Treatment 
of  Inflammatory  Phimosis. — Paraphimosis  and  its  Treatment.  .  .  .  258 


CHAPTER  III. 

COMPLICATIONS  OF  GONORRIKEA  IN  THE   MALE. 

Inflammation  of  the  Follicles  of  the  Urethra.— Follicular  and  Peri-Urethral  Ab- 
scesses.— Cowperitis. — Inflammation  of  the  Lacuna  Magna. — Death  due  to 
Gonorrhoea. — Gonorrhoeal  Cystitis.  —Gonorrhoeal  Epididymitis. — Sterility  fol- 
lowing Gonorrhoeal  Epididymitis.— Treatment  of  Gonorrhoeal  Epididymitis, 
Prophylactic  and  Curative.— The  Tobacco  Poultice.— Strapping  the  Testicle. 
— Chronic  Epididymitis. 275 


CHAPTER  IV. 

STRICTURE  OF  LARGE   CALIBRE. 

Stricture  of  the  Male  Urethra. — Spasmodic  Stricture. — Examples  of  this  Form  of 
Stricture. — Stricture  of  Large  Calibre  :  Symptoms,  Diagnosis,  Treatment. — 
Resiliary  Strictures  of  Large  Calibre. — Internal  Urethrotomy  in  the  Pendulous 
Urethra,  the  Limit  of  the  Cut,  the  Result,  and  the  After-treatment.  .  .  290 


CHAPTER  V. 

STRICTURE  OF    SMALL  CALIBRE. 

Symptoms  of  Tight  Organic  Stricture;  Diagnosis. —Expedients  for  Threading  fine 
Strictures.— Treatment  of  Stricture  of  Small  Calibre. —Continuous  Dilata- 
tion.—Internal  Urethrotomy  of  the  Deep  Urethra. — Divulsioii. — Perineal 
Section;  with  a  Guide;  without  a  Guide.— Urethral  Fever  and  its  Treat- 
ment. 


CONTENTS.  Xlll 

CHAPTER  VI. 

GONORRHO3A  IN  THE  FEMALE. 

PAGB 

Symptoms,  Complications,  Treatment. — Local  Treatment. — How  to  wash  the  Va- 
gina.— Medicated  Vaginal  Injections. — Chronic  Urethritis  and  its  Treatment. 
— Chronic  Cervicitis. — Sterility  in  Women  following  Gonorrhoea.  .  .  .  328 

CHAPTER  VII. 

COMPLICATIONS  OF  GONOBBHO3A  COMMON  TO  BOTH  SEXES. 

Gonorrhoeal  Eheumatism. — Time  of  Occurrence,  Cause,  Parts  most  often  In- 
volved.— Chronic  Hydrarthrosis. — The  Poly-articular  Form. — Neuralgia. — 
Bursitis. — Nodes. — Treatment. — Gonorrhoea!  Rheumatic  Iritis,  Conjuncti- 
vitis, Aquo-capsulitis. — Contagious  Purulent  Ophthalmia  :  its  Symptoms, 
Course,  and  Treatment 334 


INDEX  TO  ILLUSTRATIONS. 


PAGE 

FIGURE  1.  Tin  fumigating  table  and  lamp 123 

"        2.  Papular  syphilide  in  the  white, 147 

"  3.          "            "            "      negro, 149 

"        4.  Condylomatous  venereal  vegetations, 150 

"        5.  Superficial  ecthyma, 152 

"        6.  Pigmentary  syphilide, 153 

"  7.  Squamous             "               155 

"        8.  Palmar                  " 156 

"  9.  Plantar                  "               156 

"  10.  General  tubercular  syphilide, 157 

"  11.  Grouped        "              " 158 

"  12.  Rupia, 160 

"  13.  Deep  ecthyma, 161 

"  14.  Ulcerative  syphilide, 162 

"15.          "             " 162 

"  16.  Cicatrixof     " 163 

"  17.  Dactylitis  (toe), 176 

"  18.          "        (finger), 177 

"  19.          "         result  of, 178 

"  20.  Syphilitic  bursitis, 181 

"21.          "             "            181 

"  22.  Syphilitic  countenance, 243 

"  23.  Syphilitic  teeth, 244 

"  24.  Mercurial      " 245 

"25.          "            "             245 

"  26.  Urethral  syringe, 266 

"  27.  Cupped  sound 268 

"  38.  Cold         "      . 269 

"  29.  Penis  suspensory, 270 

"  30.  Bulbous  bougie, 299 

"  31.  TJrethrameter— Otis, 300 

"  32.  Conical  steel  sounds, 302 

"  33.  Urethrotome— Otis, 306 

"  34.  Urethral  tampon— Bates, 309 

"  35.  Conical  soft  bougies, 313 

"  36.  Tips  of  whalebone  bougies,     ........  813 

"  37.  TJrethrotome — Maisonneuve,      .         . 316 

"  38.  Americanized  Thompson's  divulsor, 317 

"  39.  Olivary  conical  bougie, 318 

"  40.  Lithotomy  tampon — Guyon, 319 

"  41.  Catheter  guide— Gouley,     .                         319 


THE  VENEREAL  DISEASES, 


PARTI. 


CHAPTER  I. 

CHANCROID. 

THE   NON-SYPHILITIC    VENEREAL    ULCEB. 

Chancroid. — Definition. — General  Description  of  Typical  Clinical  Chancroid. — The 
Nature  of  the  Chancroidal  Poison. — Answers  to  the  Objections  made  to  the  Ex- 
istence of  any  Special  Chancroidal  Virus,  and  Discussion  of  the  Alleged  Cases  of 
Chancroid  purporting  to  have  been  produced  by  the  Inoculation  of  Pus  not  de- 
rived from  a  Chancroid. — Is  the  Poison  of  Chancroid  a  Modified  Syphilitic  Virus  ? 
— Unity  and  Duality  in  Syphilis. — Twelve  Propositions  setting  forth  Facts  rela- 
tive to  the  Question  of  Duality,  and  believed  to  be  sustained  by  Facts,  Experi- 
mental and  Clinical,  now  before  the  Profession, 

Definition. — Chancroid  is  a  virulent  ulcer.  It  is  local  and  never  the 
starting-point  of  syphilis.  It  is  always  due  to  contact  of  the  surface  in- 
volved with  pus  derived  from  a  similar  ulcer,  and  its  own  secretions  are 
freely  auto-inoculable. 

These  characters  are  cardinal  and  uniform.  Clinically,  a  chancroid 
does  not  exist  which  does  not  fulfil  each  of  these  conditions.  A  number 
of  objective  features,  which  will  be  detailed  later,  stamp  chancroid  with 
an  especial  clinical  individuality  in  typical  cases,  but  each  of  these  latter 
special  features  is  subject  to  variation :  the  incubation  ;  the  softness  of 
the  base;  the  appearance  of  the  edges  and  of  the  surface;  the  quality  of 
the  secretion,  and  the  subjective  symptoms  also,  in  a  given  case,  all  may 
differ  from  those  found  in  the  typical  chancroid,  without  disconcerting 
the  clinical  observer.  If,  however,  a  chancroid  could  be  due  to  anything 
excepting  the  inoculation  of  chancroidal  pus — if  its  own  pus  could  fail  to 
take,  when  inoculated  for  the  first  time,  upon  the  clinical  bearer  of  the 
sore — if  chancroid  derived  from  a  chancroid  could  once  be  shown  to  be 
the  starting-point  of  true  syphilis — then  the  labors  of  Bassereau,  Clerc, 
Fournier,  and  a  host  of  others  have  been  in  vain,  and  the  profession  is 
plunged  again  into  that  obscurity  regarding  venereal  disease  which  ob- 
tained in  the  days  of  Hunter,  and  only  yielded  in  the  present  century 
to  the  campaign  inaugurated  against  it  by  Ricord. 
1 


THE    VENEKEAL    DISEASES. 


The  question  of  one  or  two  poisons  in  syphilis  will  be  discussed  later. 
Non-syphilitic  chancroid  first  claims  a  detailed  description. 


GENERAL   DESCRIPTION  OF  A  TYPICAL   CHANCROID  AS    IT    IS  CUSTOMARY    TO 
ENCOUNTER   IT    CLINICALLY. 

A  typical  chancroid,  unirritated  and  uncomplicated,  is  a  rounded  ulcer. 
In  a  furrow  it  is  oval,  large  or  small,  single  or  multiple,  simple  or  com- 
posed of  several  ulcers  which  have  run  together;  its  general  physical 
characters  are  as  constant  as  are  those  of  any  classical  cutaneous  lesion — 
as  constant,  for  instance,  as  are  the  physical  characters  of  vaccinia.  A 
faint  pink  areola  surrounds  a  chancroid.  Its  edges  are  abrupt,  sharply 
cut  at  right  angles  to  the  surface  (not  sloping  away),  very  often  slightly 
undermined,  because  the  superficial  integument  resists  the  advance  of 
the  spreading  ulcer  a  little  longer  than  the  less  dense  underlying  struc- 
tures. The  bottom  of  the  ulcer  is  either  pallid,  with  pink  granulations, 
bathed  in  thick  pus,  or,  more  often,  pultaceous,  yellow,  looking  like  dirty 
cream;  and  this  surface,  composed  of  sloughy  structures,  permeated  with 
pus,  is  adherent,  and  blood  flows  on  any  attempt  at  its  removal.  The 
structures  all  around  and  those  underlying  this  ulcer  are  perfectly  nor- 
mal, soft,  and  flexible.  The  base  of  the  ulcer  can  be  easily  lifted  up  from 
the  tissues  beneath,  and  when  rolled  between  the  thumb  and  finger  pre- 
sents no  rigidity. 

Such  an  ulcer  does  not  cause  pain.  Its  bearer  may  be  unconscious  of 
its  existence,  excepting  that  he  sees  it.  The  pus  is  creamy  and  freely 
secreted  from  the  ulcerated  surface,  and  contains  the  broken-down  de- 
tritus of  the  anatomical  elements  which  have  been  involved  in  the  pro- 
gressive march  of  the  destructive  ulcer. 

Such  is  the  simple  clinical  chancroid  as  seen  in  a  typical  case.  Many 
complications,  however,  may  attend  it  and  subject  its  appearance  to  cor- 
responding variation.  The  more  it  differs  from  the  type,  the  less  possi- 
ble is  it  for  the  surgeon  to  be  positive  in  his  diagnosis  of  its  character. 
Nothing  is  more  capable  of  correct  diagnosis  by  mere  inspection  than 
typical  chancroid;  complicated  chancroid  may  confound  the  astuteness  of 
the  closest  differential  diagnostician. 

It  is  therefore  of  the  first  importance,  in  commencing  the  study  of 
venereal  disease,  to  comprehend  what  a  chancroid  is  and  to  what  varia- 
tions it  is  liable,  especially  in  these  modern  days  when  every  ulcer  pro- 
duced by  inoculation  finds  some  sturdy  advocate  ready  to  proclaim  it  a 
chancroid. 

An  attempt  to  trace  the  history  of  chancroid  has  given  occasion  for 
the  display  of  much  erudition.  No  author  has  been  more  painstaking  in 
this  direction  than  Bassereau,1  who  brings  out  evidence  from  the  writings 
of  ancient  Greek,  Latin  and  Arabian  surgeons,  which  establishes  the  pre- 
sumption that  contagious  venereal  ulcers  have  existed  from  all  time;  and 
that  some  at  least  of  these  ulcers  were  chancroidal,  it  is  hardly  reasona- 
ble to  doubt.  Such  discussions,  however,  have  no  place  in  a  text-book 
dealing  only  with  the  practical  aspect  of  the  question. 

The  nature  of  the  poison  of  chancroid  is  unknown.  Different  ob- 
servers (Donne,  Didier,  Salisbury)  have  described  varying  parasites  as 


1  Traite  des  affections  de  la  peau  symptomatiques  de  la  syphilis.  Paris,  1852,  p 
217  et  seq. 


CHANCROID.  3 

the  essential  cause  of  chancroid;  but  no  convincing  demonstration  has 
been  given  to  the  profession  of  the  truth  of  any  theory,  and  the  world  is 
to-day  as  ignorant  of  the  nature  of  the  essential  poison  of  chancroid  as 
it  is  of  the  nature  of  the  poison  of  syphilis  or  of  scarlet  fever.  There  is 
a  growing  tendency  in  the  profession,  particularly  noticeable  of  late 
years,  to  disclaim  the  existence  of  any  poisonous  quality  in  chancroidal 
pus.  Such  well-known  authors  as  Hutchinson  of  London,  Baumler  of 
Freiburg,  and  Bumstead  of  New  York,  have  held  this  view.  The  latter, 
in  a  very  able  article  read  in  Philadelphia,  1876,  before  the  International 
Medical  Congress,  claims  that  the  inoculation  of  the  products  of  simple 
inflammation  may  produce  a  chancroid  upon  persons  who  are  syphilitic  or 
much  debilitated. 

But  why  an  ulcer,  let  it  resemble  a  chancroid  perfectly — why  such  an 
ulcer  produced  upon  a  person  in  a  pyogenic  condition  by  the  inoculation 
of  indifferent  inflammatory  pus,  should  be  called  a  chancroid,  even  although 
the  pus  be  repeatedly  auto-inoculable  in  generations,  it  is  difficult  to  un- 
derstand. Surely  a  pustule  of  acne  is  not  a  chancroid.  If  it  were  a 
chancroid  it  would  spread  peripherally  and  behave  like  that  classic  ulcer. 
The  auto-inoculability  in  generations,  of  pus  derived  from  a  pustule  of 
acne,  confirms  the  well-known  conclusions  of  Von  Roosbroeck,  that  all 
pus  is  more  or  less  irritating,  more  or  less  contagious.  Many  individuals 
in  poor  health  notoriously  "fester"  when  they  are  scratched,  without  re- 
quiring the  inoculation  of  any  substance  to  produce  a  suppurating  sore. 
The  violence  done  to  the  skin  shows  up  the  quality  of  the  latter,  and  it  is 
the  pus-forming  tendency  which  develops  the  ulcer  upon  a  patient  whose 
integument  may  be  subjected  to  violence  of  a  mechanical  or  of  a  chemi- 
cal sort,  and  not  necessarily  any  poison  introduced  from  without. 

If  chancroid  could  be  produced  de  novo  by  the  inoculation  of  ordinary 
pus  upon  syphilitic  and  cachectic  persons,  the  number  of  chancroids  clin- 
ically observed  upon  respectable  people,  syphilitic  and  cachectic,  would 
be  vastly  greater  than  it  is.  Balanitis  (from  tight  prepuce),  suppura- 
ting herpes  progenitalis,  gonorrhoea,  and  suppurative  leucorrhcea  in  the 
female,  are  very  common  in  such  patients,  but  chancroid  is  exceedingly 
rare  among  respectable  people,  and  does  not  occur  (so  far  as  the  writer 
knows)  clinically,  excepting  under  circumstances  which  allow  an  opportu- 
nity for  contagion,  direct  or  indirect,  with  the  secretion  of  a  similar  ulcer. 

The  experiments  of  Pick,  Koebner,  Kaposi,  Kraus,  Reder,  Lee,  Bid- 
enkap,  Morgan,  Wigglesworth,  Von  Roosbroeck  and  others,  demonstrate 
that  all  sorts  of  irritating  secretions  may  produce  ulcers  and  auto-inocu- 
lable ulcers;  but  no  one  has  shown  that  the  minute  prick  of  a  pin  dipped 
in  such  pus  will  produce  an  ulcer  yielding  a  chancroidal  bubo — the  virulent, 
not  the  simple  suppurating  bubo.  No  one  has  produced  a  typical  chan- 
croidal ulcer  by  inoculating  from  a  half-glass  of  water  in  which  one  drop 
of  simple  inflammatory  pus  had  been  placed — as  did  Puche  with  a  drop 
of  chancroidal  pus.  And  Boeck,  the  sturdy  advocate  of  syphilization, 
would  certainly  not  have  gone  to  the  trouble  of  collecting  chancroidal 
pus  in  the  hospitals  of  Christiania  to  send  into  the  surrounding  country 
for  the  purpose  of  syphilization,  if  ordinary  pus  would  have  done  as  well. 
Boeck  himself  stated  that  chancroidal  pus  would  yield  positive  results  to 
inoculation  even  when  diluted  with  eleven  hundred  parts  of  ordinary 
pus. 

Some  years  since,  at  the  Charity  Hospital,  I  endeavored  to  produce 
cutaneous  ulcers  by  inoculation  of  indifferent  patients  with  indifferent 
pus,  but  the  experiments  were  not  long  continued,  for,  although  some 


4  THE    VENEREAL    DISEASES. 

pustules  were  obtained,  nothing  resembling  the  rapidly  spreading  destruc- 
tive chancroid  appeared. 

Tarnowsky,  an  excellent  and  competent  observer,  declares '  as  deduc- 
tions from  a  number  of  experiments,  that  the  sores  produced  upon  syphi- 
litic persons  by  Bidenkap,  Reder,  and  Koebner,  are  distinguishable  by  their 
form,  course,  absence  of  bubo,  and  results,  from  true  chancroid,  and  are 
only  the  characteristic  effects  of  the  irritation  of  the  skin  in  syphilitics. 
He  believes  that  any  irritant,  if  strong  enough,  will  produce  like  results. 
He  states  that  inoculation  from  these  sores  upon  healthy  subjects  may 
produce  syphilis,  but  not  chancroid. 

Zarewicz "  of  Krakau  inoculated  syphilitic  products  upon  syphilitics. 
Pus  was  taken  from  the  lesions  so  produced  (without  admixture  of  blood) 
and  inoculated  upon  healthy  persons,  always  with  negative  results,  while 
the  same  pus  yielded  positive  results  when  inoculated  upon  syphilitic 
persons.  This  proves  that  the  lesion  was  not  a  chancroid  and  was  not 
syphilis,  but  simply  that  irritating  pus  could  be  positively  inoculated  upon 
syphilitic  persons,  while  the  same  inoculations  were  negative  upon  healthy 
persons. 

On  the  other  hand,  a  claim  has  been  made  by  Bidenkap  and  Gjor 
(quoted  by  Bumstead),  that  five  patients,  not  themselves  syphilitic, 
inoculated  themselves  from  sores  produced  by  inoculation  of  the  pro- 
ducts of  an  irritated  syphilitic  chancre  upon  syphilitic  patients,  and  that 
while  the  inoculated  ulcers  took  (like  chancroids)  upon  these  healthy 
persons,  only  one  of  them  became  syphilitic,  and  in  that  case  syphilis  was 
doubtful. 

Only  one  of  these  cases  is  important,  and  that  one  at  first  sight  seems 
convincing.  It  is  described  by  Bidenkap,  and  originally  appeared  in  the 
Wiener  Med.  Wchnschrft.  of  1865  (No.  34). 

A  young  woman,  free  from  syphilis  (in  the  hospital  on  account  of  ure- 
thral  and  vaginal  suppuration),  inoculated  herself  with  a  needle  through 
curiosity,  from  ulcers  which  Bidenkap  had  produced  upon  a  syphilic  pa- 
tient by  first  taking  pus  from  an  irritated  syphilitic  chancre  and  reinocula- 
ting  i*  through  many  generations.  An  ulcer  lasting  two  months  and  pro- 
ducing another  by  spontaneous  inoculation  was  the  result  upon  the  young 
woman — but  no  syphilis.  Eighteen  months  later  she  acquired  syphilis  in 
the  usual  way. 

The  facts  in  this  case  may  be  explained  as  follows:  whatever  syphilitic 
poison  taken  from  the  chancre  was  inoculated  upon  the  syphilitic  patient 
from  whom  the  young  woman  got  her  pus,  died  out,  since  syphilitic  virus 
does  not  propagate  itself  by  auto-inoculation.  Acrid  pus,  auto-inoculable 
in  generations,  only  was  left  behind,  and  this  the  young  woman  used,  not 
getting  any  blood,  and  therefore  avoiding  contamination  of  the  pus  she 
used  with  any  of  the  true  poison  of  syphilis.  Had  the  true  poison  of 
syphilis  been  inoculated  she  must  have  had  chancre,  which  she  did  not 
have;  not  having  chancre,  did  she  have  chancroid?  There  is  nothing  in 
the  case  to  show  that  the  syphilis  of  the  patient  furnishing  the  pus  was 
active  at  the  time  the  pus  was  taken  by  the  young  woman,  and  there  is 
nothing  to  show  that  other  irritating  pus,  such  as  that  found  in  simple 
ecthyma,  or  in  scabies,  might  not  have  also  taken  upon  the  young  woman, 
if  properly  inoculated,  and  have  produced  an  indolent  ulcer,  itself  auto- 


:  Vrfcljahresschrift.  f.  Derm.  u.  Syph.  I.  and  II.  1877. 

s  Prom  a  review  by  Ettinger :  Jahresbericht  ueber  die  Liestungen  und  Fortschritte 
in  der  Gesmtn.  Med.     II. ,  ii. .  1878,  p.  529. 


CHANCROID.  0 

inoculable.  She  had  a  suppurating  urethritis  and  vaginitis,  and  her  posi- 
tion in  the  pyogenic  scale  was  probably  high. 

There  is  no  law  which  compels  all  the  pathological  secretions  upon  a 
person  who  is  syphilitic  to  carry  with  them  any  portion  of  the  true  syphi- 
litic virus  by  necessity. 

On  the  contrary,  if  not  admixed  with  blood,  such  secretions  are  not 
poisonous — in  a  syphilitic  way.  It  is  notorious  that  a  chancroid  upon  a 
syphilitic  patient  may  clinically  even  reproduce  either  chancroid  alone  or 
mixed  chancre  followed  by  syphilis.  In  the  latter  case  doubtless  some 
blood  gets  inoculated  with  the  chancroidal  pus.  This  case,  therefore,  de- 
monstrates nothing. 

Conflicting  evidence  of  this  sort  demands  great  consideration  and  care 
before  deductions  can  be  drawn  from  it.  Extensive  experimentations 
from  syphilitics  to  non-syphilitics  is  not  justifiable,  and  voluntary  experi- 
ments made  by  patients  who  declare  themselves  free  from  syphilis  must 
be  received  with  great  caution. 

Clinically,  however,  there  is  certainly  no  question  that  chancroid  is 
derived  (for  practical  purposes)  always  from  contact  of  the  part  involved 
with  the  secretions  of  a  chancroid.  Inflammatory  products  are  not  known 
clinically  to  produce  chancroids  upon  healthy  people,  and  it  is  begging 
the  question  to  claim  that  they  do  so,  simply  because  an  ulcer  may  be 
produced  upon  a  syphilitic  or  upon  an  unhealthy  person  by  inoculating 
him  with  indifferent  pus. 

It  is  well  known  that  the  pus  of  impetigo  is  not  contagious  clinically 
upon  being  ordinarily  handled;  yet  who  is  unfamiliar  with  the  fact  that 
an  impetiginous  child  (or  adult)  is  apt  to  have  a  prompt  outcrop  of  pus- 
tules upon  any  part  overlying  another  part  which  is  secreting  pus,  and  to 
get  pustules  readily  upon  spots  where  such  pus  has  been  deposited  by 
the  nails  ?  Yet  certainly  these  facts  do  not  militate  against  the  non-con- 
tagious  clinical  quality  (for  others)  of  the  pus  of  impetigo. 

The  inoculable  quality  of  true  chancroidal  pus  is  a  free,  frank, 
virulent,  rapid  inoculability. — Such  pus  takes  at  once,  upon  the  per- 
son bearing  the  sore,  in  an  unmistakable  manner.  The  healthiest  by- 
stander may  be  made  the  subject  of  successful  experiment — an  experi- 
ment always  successful — unless  the  capacity  of  the  skin  to  produce  pus 
has  been  overcome  by  prolonged  inoculations,  as  in  syphilization.  The 
incautious  surgeon  with  a  fissure  on  his  finger  learns  the  virulent  inocu- 
lability of  chancroidal  pus  to  his  sorrow,  and  he  afterward  handles  a  sus- 
pected case  with  the  utmost  circumspection,  while  he  thrusts  the  same 
cracked  finger  into  the  cavity  of  an  abscess  full  of  pus  without  taking  the 
least  precaution  or  experiencing  any  evil  result.  For  the  successful  he- 
tero-  or  auto-inoculation  of  the  clinical  chancroid,  no  syphilis  of  the  sub- 
ject inoculated  is  necessary  to  secure  a  take,  and  no  cachexia. 

Is  there  then  no  difference  between  the  pus  of  chancroid  and  that  of 
ordinary  ulcerative  inflammation  ?  Assuredly  there  is.  And  what  is 
this  difference?  Certainly  we  do  not  know  what  it  is,  but  we  know  that 
it  is  a  virulent  quality,  and  we  call  it  a  virus,  a  poison,  not  distinguish- 
able in  the  pus  by  any  microscopical  or  chemical  quality  yet  described, 
not  due  to  any  parasite  yet  discovered,  but  none  the  less  a  virus  than  the 
virus  of  the  rattlesnake — a  virus  also  imponderable  and  intangible  by  any 
of  the  tests  known  to  science.  By  its  fruits  it  is  known,  by  its  effects  its 
qualities  are  disclosed. 

Is  the  poison  of  chancroid  a  modified  syphilitic  poison? — 
There  is  not  one  fact  to  prove  it.  It  behaves  differently  in  all  respects. 


6  THE    VENEREAL    DISEASES. 

A  true  chancroid  certainly  cannot  produce  syphilis,  and  if  syphilis  can 
produce  something  resembling  chancroid,  even  yet  identity  is  not  estab- 
lished unless  the  compliment  can  be  returned,  and  this  has  never  been 
proved  to  be  the  case.  Lindmann's  2,700  inoculations  upon  himself  did 
not  exhaust  his  power  of  still  producing  successful  chancroids  upon  his 
own  person.  This  does  not  resemble  anything  known  of  syphilis.  Long 
before  reaching  this  number,  believing  himself  protected  by  his  inocula- 
tions (on  account  of  the  doctrines  of  syphilization),  he  inoculated  himself 
once  with  matter  taken  from  the  tonsils  of  a  friend  who  had  syphilis. 
This  inoculation  also  took,  and  after  forty-five  days  a  syphilitic  eruption 
appeared.  The  doctor  then  resumed  his  chancroidal  inoculations,  but 
•with  less  faith  than  before  in  the  protective  value  of  syphilization. 

Warnery  of  Lausanne,  and  Danielssen's  case,  are  also  classical  examples 
of  the  lack  of  similarity  between  chancroid  and  syphilis.  The  former, 
after  frequently  inoculating  himself  with  chancroid  and  getting  only  local 
ulcers,  finally  used  the  secretion  from  a  syphilitic  chancre  once,  and  gen- 
eral syphilis  ensued.  Danielssen  produced  chancroids  upon  a  patient 
two  hundred  and  eighty-seven  times,  until  the  pus-forming  capacity  of 
the  skin  had  been  temporarily  exhausted  and  chancroidal  pus  failed  any 
longer  to  yield  positive  results.  •  Then  the  discharge  from  a  syphilitic 
chancre  was  used,  and  syphilis  resulted.  Meantime  the  suppurative  ca- 
pacity of  the  skin  had  returned  on  account  of  the  rest  allowed  to  it,  and  a 
new  inoculation  of  chancroids  was  instituted.  These  took,  and  the  patient, 
whose  original  disease  was  Norwegian  leprosy,  was  again  "syphilized" — 
to  his  own  satisfaction,  doubtless,  certainly  to  that  of  Danielssen.  The 
case  originally  was  reported  in  the  Deutsche  Klinik  for  1858,  p.  322.  It 
has  since  been  quoted  everywhere,  and  has  done  much  to  shake  the  faith 
of  the  advocates  of  syphilization  in  the  value  of  that  proceeding  as  a 
prophylactic. 

These  few  cases  place  it  beyond  question  that  the  poison  of  true 
syphilis  is  not  contained  in  chancroidal  pus.  None  of  the  cases  would 
have  existed  excepting  for  the  pleasing  fiction  of  Auzias  Turenne,  which 
he  termed  syphilization,  and  which  at  one  time  had  many  adherents  in 
the  profession  in  different  parts  of  Europe.  Syphilization — the  repeated 
inoculation  of  chancroidal  pus  upon  an  individual  until  the  skin  failed 
any  longer  to  respond  to  the  irritation,  and  chancroids  could  no  longer  be 
produced  upon  inoculating  chancroidal  pus — this  syphilization  was  pro- 
posed as  a  means  to  be  generally  adopted  for  the  purpose  of  furbishing 
immunity  to  the  poison  of  true  syphilis.  How  little  immunity  was  fur- 
nished is  shown  by  the  cases  described  above. 

Two  points  then  seem  to  be  clear:  (1)  chancroid  pus  is  more  freely 
inoculable  than  pus  derived  from  any  other  source;  it  will  take  in  a  char- 
acteristic manner  upon  a  healthy  person  as  well  as  upon  one  who  is  syph- 
ilitic or  cachectic  ;  and  (2)  the  poison  of  true  syphilis  is  not  contained  in 
chancroidal  pus. 

If  now  these  two  points  have  been  demonstrated,  what  is  it  that  con- 
stitutes the  virulence  of  chancroid  and  makes  its  pus  more  irritating  than 
pus  derived  from  other  sources  ?  There  is  but  one  reasonable  reply  to 
this  question,  namely:  there  is  a  poison,  a  virus  in  chancroidal  pus,  pecu- 
liar to  itself,  not  capable  of  being  generated  de  novo,  not  syphilitic  in 
nature,  but  sui  generis,  an  entity  in  itself.  We  do  not  know  what  this 
poison  is,  but  by  its  effects  its  existence  may  be  claimed.  The  advocates 
of  the  simple  inflammatory  nature  of  the  ulcer  have  failed  to  furnish  con- 
vincing demonstration  of  their  claims  even  scientifically,  while  clinically 


CHANCROID.  7 

no  confrontation  and  no  single  sporadic  case  has  been  reported  (so  far  as 
the  writer  knows)  showing  that  a  typical  clinical  chancroid  has  originated 
de  novo. 

The  poison  of  chancroid  not  being  the  poison  of  true  syphilis,  is  it  a 
modification  of  that  poison  ? 

This  position  is  very  stoutly  maintained  by  a  respectable  minority  in 
the  profession,  the  notion  being  that  the  syphilitic  poison,  when  nearly 
exhausted  in  virulence,  may  produce  a  chancroid,  or  that  secretions  of  or- 
dinary ulcers  upon  syphilitic  subjects  become  capable  of  auto- inoculation, 
and  that  the  hetero-inoculation  of  such  secretions  produces  chancroids. 
This  reduces  chancroid  to  the  condition  of  a  bastard  ;  but  even  if  this 
state  of  affairs  could  be  absolutely  proved,  it  would  be  unwise  clinically 
to  admit  of  any  relationship  between  chancroid  and  syphilis.  A  theoret- 
ical relationship,  while  seemingly  facilitating  diagnosis  and  leading  to 
that  grateful  sense  of  accurate  knowledge  so  agreeable  to  the  searcher 
after  truth,  is  certain  to  add  still  further  to  the  existing  confusion  in  diag- 
nosis and  hopelessly  to  confound  all  intelligence  in  therapeutics. 

The  conservative  position  now  held  by  the  majority  of  writers  upon 
syphilis  is  undoubtedly  the  safest  one.  It  is  this:  syphilis  is  a  blood  dis- 
ease, and  chancre  is  its  first  symptom.  Chancroid  is  a  local  ulcer  and  is 
not  associated  with  any  poisoning  of  the  blood  or  productive  of  it.  A 
conviction  of  the  truth  of  these  statements  is  the  only  safe  guide  to  ther- 
apeutics. It  spares  the  physician  much  confusion  and  many  a  patient 
years  of  unnecessary  anxiety. 

Practically,  the  doctrine  is  productive  of  much  comfort,  leaving  very 
little  room  for  annoyance  to  either  physician  or  patient,  and  this  annoy- 
ance only  that  of  differential  diagnosis  of  the  primary  lesion  in  difficult 
cases.  This  latter  difficulty  is  always  removed  by  observation  during  a 
few  weeks,  the  loss  of  which  is  not  material  should  the  malady  in  the  end 
prove  to  be  syphilis. 

Unity  and  duality  in  syphilis. — The  foregoing  consideration  of 
the  nature  of  the  chancroidal  virus  leads  so  directly  to  the  question  of 
unity  or  duality  in  syphilis  that  a  few  words  upon  this  subject  will  be 
more  appropriate  in  this  context  than  in  its  more  natural  position  under 
the  head  of  syphilis.  The  detail  of  the  battles  that  have  been  fought  over 
this  question,  with  the  array  of  cases  on  either  side,  is  a  wearisome  matter. 
A  full  consideration  of  the  long  series  of  articles  written  upon  it  would 
take  more  space  than  this  volume  can  afford,  and  would  be  flat  and  unpro- 
fitable to  the  general  reader.  An  excellent  array  of  the  cases  and  argu- 
ments is  presented  by  Baumler  in  Ziemssen's  Cyclopedia. 

A  resume  of  the  points  which  seem  to  be  established  at  the  present 
date  is  all  that  is  appropriate  here. 

When  syphilis  first  began  to  be  written  about,  after  the  outbreak  at  the 
end  of  the  fifteenth  century,  when  it  went  under  the  name  (generally)  of 
the  French  disease,  it  was  uniformly  recognized  as  a  new  malady.  It  was 
not  confounded  with  other  venereal  maladies  known  at  that  date,  but  was 
uniformly  described  as  a  morbus  novus,  inauditus,  incognitus,  etc.  The 
writers  who  described  it  gave  vent  to  their  surprise  in  their  words,  and 
were  unanimous  in  that  expression.  As  Bassereau  puts  it:  "There  was 
one  point  upon  which  there  was  not  the  least  difference  of  opinion  be- 
tween them;  upon  which  the  oldest,  the  youngest,  the  wisest  and  the  most 
ignorant  were  of  unanimous  accord,  namely  :  that  none  of  them  had  ever 
observed  anything  analogous  or  similar  to  the  French  disease  before  the 
arrival  of  Charles  VIII.  in  Italy." 


8  THE    VENEREAL    DISEASES. 

Soon,  however,  writers  began  to  compare  the  new  disease  with  other 
venereal  maladies,  and  finally,  in  1551,  Musa  Brassavole  united  all  the 
diseases  together  and  included  them  in  the  history  of  syphilis. 

From  that  time,  the  end  of  the  sixteenth  until  the  present  century, 
the  doctrine  of  syphilis  was  almost  uniformly  that  of  unity.  Gonorrhoea, 
all  sorts  of  vegetations  and  all  varieties  of  local  ulcers,  were,  along  with 
the  expressions  of  true  syphilis,  considered  to  be  evidences  of  the  action 
of  some  internal  blood-poison,  some  humor.  In  England,  the  powerful 
brain  of  Hunter  unfortunately  fell  into  the  wrong  track  in  its  interpreta- 
tion of  facts.  Hunter  had  inoculated  himself  from  an  urethral  discharge 
and  got  syphilitic  chancre  at  the  spot  inoculated.  His  own  case  was 
published  to  the  world;  no  one  had  thought  of  such  a  thing  as  an  urethral 
chancre,  and  the  identity  of  gonorrhoea  and  syphilis  seemed  to  be  estab- 
lished. Thousands  of  simple  cases  of  gonorrhoea  were  salivated  on  ac- 
count of  this  error,  strengthened  and  sustained  as  it  was  by  Hunter's 
unfortunate  experience. 

Ricord,  in  Paris,  in  translating  Hunter's  writings  and  making  his  own 
clinical  observations,  soon  decided  that  gonorrhoea  and  syphilis  were  very 
different  maladies,  and  he  first  clearly  demonstrated  the  difference  be- 
tween them.  This,  indeed,  is  his  greatest  achievement. 

Ricord  also,  by  a  close  study  of  the  primary  lesion,  detected  differences 
in  their  physical  characters,  and  noticed  that  some  sores  on  the  penis  ac- 
quired in  sexual  contact  were  followed  by  evidences  of  general  syphilis, 
while  others  were  not.  He  did  not  clearly  at  first  make  out  a  difference  in 
the  originating  cause  of  these  ulcers,  although  he  intimated  it.  He  stated 
that  all  chancres  were  not  alike:  that  some  of  them  took  on  induration, 
while  others  did  not;  that  those  which  became  indurated  were  followed 
by  general  symptoms  and  called  for  general  treatment,  while  those  which 
remained  soft  were  injured  by  mercury,  did  not  call  for  anything  except 
local  treatment,  and  did  not  poison  the  blood. 

In  a  thesis  by  Prieur,1  Paris,  1851,  even  in  his  Lettres  sur  la  syphilis, 
1850,  Ricord  put  out  the  first  ideas  of  dualism  in  the  syphilitic  doctrine, 
intimating  in  the  latter  treatise,  in  regard  to  syphilization,  that  perhaps 
the  induration  in  some  chancres  and  its  absence  in  others  was  due  to  a 
difference  in  cause,  and,  in  the  thesis,  stating  that  in  his  experience  the 
transmission  of  non-indurated  chancre  to  healthy  subjects  always  pro- 
duced its  like,  while  indurated  chancre  always  recognized  a  similar  lesion 
as  its  point  of  origin. 

In  1852,  Leon  Bassereau,  by  a  review  of  laborious  confrontations,  es- 
tablished the  individuality  of  chancroid,  and  made  it  evident  to  the  world 
that  venereal  ulcers  belonged  to  two  distinct  families,  the  one  non-indu- 
rated and  local,  the  other  indurated  and  followed  by  syphilis. 

This  is  the  doctrine  of  dualism.  Clerc,  following  Bassereau,  strength- 
ened it.  Ricord  approved  it  formally  in  1858,  and  gave  it  widespread 
circulation  by  the  weight  of  the  influence  his  high  authority  in  venereal 
disease  allowed  him  to  exercise.  Ricord  had  dissented  from  this  view  at 
first,  but  upon  his  adoption  of  it  the  adherents  to  the  doctrine  of  unity  of 
the  syphilitic  poison,  i.  e.,  similarity  of  cause  in  the  production  both  of 
the  indurated  and  the  non-indurated  sore,  received  a  blow  from  which 
they  have  never  recovered. 

Long  years  before  this  time  inoculations  had  been  practised — both 
auto-  and  hetero-inoculation.  Hunter  had  established  experimentally  that 

1  Quelques  questions  sur  la  syphilis. 


CHANCROID.  9 

indurated  chancre  was  not  inoculable  upon  its  bearer  or  upon  another 
person  already  syphilitic,  and  syphilization  had  been  practised  since  its 
discovery  by  Auzias  Turenne  in  1844,  the  pus  being  taken  from  non-indu- 
rated sores.  Yet,  in  spite  of  a  general  knowledge  of  these  facts,  they 
were  not  correctly  appreciated  until  the  labors  of  Bassereau  translated 
them  and  demonstrated  dualism  to  the  world. 

Matters  went  smoothly  enough  for  a  time.  The  term  dualism,  how- 
ever, was  an  unfortunate  one.  Its  advocates  did  not  mean  precisely  that 
there  were  two  poisons  in  syphilis.  On  the  contrary,  they  were  unicists 
and  believed  that  there  was  one  and  only  one  syphilis,  and  another  distinct 
virulent  disease,  known  under  different  names,  but  best  recognized  in  this 
country  by  Clerc's  denomination — chancroid. 

The  dualists  became  over-confident  in  the  strength  of  their  new  posi- 
tion and  began  to  make  very  bold  assertions,  allowing  but  little  or  no 
chance  for  exceptions. 

The  Hunterian  chancre  was  spoken  of  a  great  deal,  but  it  has  turned 
out  that  this  is  one  of  the  rather  rare  initial  lesions  of  syphilis,  the  indu- 
rated erosion  being  more  uniformly  the  point  of  entrance  of  the  disease. 
Soft  chancre  and  hard  chancre  came  to  indicate  necessarily  in  the  minds 
of  many  (as  they  still  unfortunately  do),  the  one  a  local  non-syphilitic 
ulcer,  the  other  always  the  point  of  entrance  of  syphilis.  A  final  misfor- 
tune was  the  adoption  of  the  tenet  that  a  soft  sore  could  be  always  auto- 
inoculated  and  a  hard  sore  never,  implying  that  anything  which  could  be 
auto-inoculated  was  a  chancroid.  Then,  that  syphilis  could  only  be  due 
to  infection  by  a  hard  chancre,  etc.,  until  the  advocates  of  so-called  dual- 
ism had  so  weakened  their  position  by  positive  statements  that  their  ene- 
mies threatened  the  integrity  of  the  entire  structure  by  picking  flaws  in 
every  portion  of  the  too  confident  argument. 

It  turns  out  now  that  competent  observers  are  ready  to  testify  on  all 
sides  that  they  see  syphilis  succeeding  local  ulcers  which  are  not  indurated. 
Cases  are  bountifully  adduced  to  show  that  all  sorts  of  purulent  secretions 
are  more  or  less  inoculable,  according  to  the  quality  of  the  secretion  and 
the  nature  of  the  individual.  Other  cases  show  that,  after  repeated  inocu- 
lation, chancroidal  pus  at  last  fails  to  take.  Syphilitic  chancres  may  be 
auto-inoculated,  and  such  pus  reinoculated  may  finally  produce  an  auto- 
inoculable  pus  which  does  not  necessarily  contain  the  syphilitic  poison. 
Many  of  the  later  lesions  of  syphilis  are  auto-inoculable.  The  auto-inocu- 
lation of  syphilitic  chancre  may  produce  an  abortive  pustule,  or  a  papule, 
or  nothing.  Syphilis  may  be  acquired  twice  by  the  same  individual. 
Finally,  a  chancre  may  be  first  soft,  later  hard,  and  be  followed  by  syphilis; 
and  again,  a  chancroid  may  be  exceedingly  hard  and  yet  not  at  all  followed 
by  syphilis. 

Cases  have  been  adduced  in  support  of  all  these  facts,  and  still  others 
to  show  that  syphilitic  chancre  may  follow  inoculation  of  blood,  or  of 
secretions  of  secondary  lesions,  while  phagedsena  and  suppurating  bubo 
are  shown  to  be  not  at  all  the  prerogatives  of  chancroid. 

In  face  of  all  these  facts  what  justification  can  the  doctrine  of  two 
poisons  find — the  doctrine,  call  it  unity  or  duality — which  claims  that 
chancroid  is  one  disease  due  always  and  only  to  inoculation  of  chancroidal 
pus,  and  syphilis  another  disease  due  always  and  only  to  contamination 
with  the  syphilitic  virus,  directly  by  the  individual,  or  indirectly  by  in- 
heritance ? 

In  order  to  explain  away  these  exceptional  cases  in  so  far  as  they 
threaten  the  above  doctrine,  without  detailing  all  the  cases,  it  will  be  ex- 


10  THE    VENEREAL    DISEASES. 

pedient  to  note  the  deviations  from  the  rules  formerly  considered  absolute, 
and  to  accompany  each  by  its  explanation.  Cases  need  to  be  referred  to 
by  name  only.  They  are  most  of  them  well  known,  and  have  been  so  gen- 
erally quoted  and  requoted  in  the  different  books  written  upon  syphilitic 
subjects  that  the  student  can  easily  find  them.  This  bird's-eye  view  will 
give  a  more  comprehensive  general  understanding  of  the  condition  of  the 
subject  at  the  present  day  than  any  other  which  could  be  crowded  into 
the  space  at  hand.  The  following  twelve  propositions  rest  upon  such 
positive  proof  that  they  can  hardly  fail  to  be  accepted. 

1.  Chancroid  upon  a  non-syphilitic  patient  is  easy  to  com- 
municate to  any  one,  but  in  no  such  case  among  millions  ob- 
served has  the  inoculation  been  followed  by  syphilis. — This  bul- 
wark of  dualism  has  received  no  blow.     It  is  as  firm  to-day  as  it  was  in 
the  time  of  Bassereau's  investigations. 

2.  A  non-indurated  ulcer  may  be  the  starting-point  of  syph- 
ilis.— Every  surgeon  of  large  experience  sees   this.     It   has  been  espe- 
cially noticed  in  the  female  that  the  syphilitic   chancre  often  remains 
soft,  and  the  occurrence  upon  the  male  of  a  soft  syphilitic  chancre  is  not 
so  infrequent  as  to  be  phenomenal.     But,  induration  is  only  one  feature 
of  syphilitic  chancre — a  very  common  one  undoubtedly,  nearly  constant; 
but  the  primary  syphilitic   lesion  may  exist  without  it.     Scarlet    fever 
without  the  rash  is  none  the  less  scarlet  fever.     The    so-called   black 
measles  (without  a  single  pustule)  is  now  known  to  be  suppressed  malig- 
nant small-pox  in  many  cases,  and  it  is  none  the  less  small-pox  because 
the  characteristic  pustule  is  absent.     If  the  other  features  of  the  chancre 
accord  with  the  type,  and  syphilis  follows,  and  the  chancre  has  originated 
from  contact  with  syphilitic  poison,  assuredly  it  is  not  a  chancroid  simply 
because  it  is  soft.     It  requires  more  than  one  symptom  to  make  a  disease. 
A  phagedenic  syphilitic  chancre  is  customarily  non-indurated. 

3.  A  chancroid  may  be  indurated  and  not  be  followed  by 
syphilis. — A  hard  chancroid  is  much  more  common  clinically  than  a 
soft  syphilitic  chancre.     The  induration  of  chancroid,  however,  is  inflam- 
matory and  not  specific,  and  it  is  generally  as  easy  to  distinguish  this  in- 
flammatory hardness  from  the  induration  of  syphilis  as  it  is  to  tell  moon- 
light from  sunlight.     There  are  cases,  however,  in  which  it  is  impossible 
to  make  a  diagnosis,  if  the  induration  alone  is  relied  upon.1     In  such 
cases  the  prudent  surgeon  reserves  his  judgment  until  other  signs  have 
come  to  make  a  diagnosis  for  him.     There  are  other  symptoms  of  chan- 
croid far  more  distinctive  than  the  lack  of  hardness.     A  hard  ulcer  is  by 
no  means  simply  on  that  account  a  syphilitic  sore. 

4.  Hunterian  chancre  so-called  has  come  with  many  to  sig- 
nify syphilitic  chancre.    The  truth  is,  that  Hunterian  chancre  is 
only  one  of  the  varieties  of  initial  lesion. — Other  forms  of  the  pri- 
mary lesion  are  just  as  characteristic  and  just  as  syphilitic  as  Hunterian 
chancre,  and  one  of  the  lesions  is  much  more  common,  namely,  the  in- 
durated erosion — not  an  ulcer  at  all. 

5.  A  chancroid  is  not  indefinitely  auto-inoculabie. — The  capa- 
bility of  the  skin  to  furnish  ulcers  upon  local  irritation  of  the  proper  sort 
has  its  limit.     The  early  investigators  were  too  positive  in  their  state- 

1  Such  cases  have  been  on  several  occasions  brought  before  the  New  York  Dermato- 
logical  Society,  a  society  reasonably  expert  in  such  matters,  and  have  given  rise  to 
hot  discussion,  and  sometimes  to  nearly  an  equal  division  of  opinion  among  the  mem- 
bers of  that  body,  as  to  their  probable  syphilitic  or  non-syphilitic  character. 


CHANCROID.  11 

ments  ?bout  chancroidal  pus.  Truly  it  is  very  virulent.  A  patient  in  high 
fever1  will  take  it;  cancer,  leprosy,  syphilis,  a  previous  chancroid,  none 
of  these  prevent  a  take  if  chancroidal  pus  is  properly  inoculated.  The 
syphilizers  of  Norway,  however,  following  Auzias  Turenne,  have  clearly 
demonstrated  that  the  skin  may  be  worn  out  in  its  capacity  of  responding 
to  the  repeated  inoculation  of  chancroidal  (or  other  pus).  The  same 
thing  has  been  found  to  happen  when  the  integument  is  kept  long  sup- 
purating by  other  irritants — as  by  tartar  emetic.  After  a  period  of  rest 
the  skin  will  again  respond  upon  inoculation,  and  the  patient  may  be  again 
repeatedly  inoculated  until  again  the  inoculation  will  no  longer  take. 

These  facts  would  seem  strange  did  we  not  have  analogies  in  common 
life.  People  who  handle  bees  at  first  become  poisoned  when  stung,  and 
the  wounded  parts  swell  and  inflame  considerably.  After  a  time,  how- 
ever, the  stinging  fails  to  produce  any  more  local  disturbance,  and  the 
sharp  feeling,  at  the  moment  of  being  stung,  is  the  only  discomfort  ex- 
perienced. After  a  long  interval,  during  which  no  bees  are  handled,  the 
sting  again  produces  inflammatory  trouble.*  In  some  individuals  the 
same  remarks  apply  to  the  bite  of  the  mosquito. 

Inability  of  the  skin  to  produce  pus  upon  inoculation  does  not,  as  the 
syphilizers  have  hoped,  prevent  it  from  absorbing  the  poison  of  true 
syphilis  at  once,  as  shown  by  Lindmann  upon  himself,  and  in  Danielssen's 
case.  The  value  of  these  cases  to  dualism  is  hard  to  over-estimate. 

6.  Pus,  not  ehancroidal  and  not  syphilitic,  may  be  inocu- 
lated in  generations,  as  it  is  called,  may  produce  a  series  of  auto-in- 
oculable  ulcers  upon  the  same  individual,  the  pus  of  the  last  ulcer  being 
used  to  start  the  next  one  (Pick,  Lee,  Wigglesworth,  Kraus,  Reder,  L. 
Vidal,  Kaposi,  Bidenkap,  and  others.) 

Here  again  the  enemies  of  dualism  take  advantage  of  the  assertions 
of  over-confident  men,  and  endeavor  to  break  down  a  very  practical  doc- 
trine by  a  successful  attack  upon  one  of  the  outposts.  But,  although 
chancroid  is  an  auto-inoculable  ulcer,  an  auto-inoculable  ulcer  is  by  no 
means  necessarily  a  chancroid.  Impetigo  and  eczema  produce  suppura- 
tion by  auto-inoculation  of  overlying  integument  sometimes — and  are 
not  on  this  account  chancroids.  All  sorts  of  pus  have  been  successfully 
used  for  this  purpose,  with  the  effect  of  demonstrating  that  some  pus 
takes  much  more  easily  than  other  pus. 

A  great  difference  also  is  found  in  individuals :  some  take  easily, 
some  with  difficulty,  some  not  at  all.  Syphilitic  persons  and  cachectic 
persons  form  the  best  subjects  for  inoculation.  It  is  well  known  that 
some  persons  fester  easily  upon  local  injury,  others  with  difficulty.  A 
patient  with  cachectic  ecthyma  may  be  scratched  with  a  clean  pin  and 
the  spot  v/iay  suppurate.  It  is  well  known  that  where  the  skin  of  such 
patients  is  subjected  to  injury,  pus  is  very  apt  to  be  formed.  The  more 
or  less  irritating  and  contagious  quality  of  all  pus  is  getting  to  be  a  doc- 
trine quite  generally  recognized  by  those  who  study  inflammation. 

After  the  inoculation  of  indifferent  pus  an  ulcer  has  not  been  shown 
to  be  produced  yielding  a  virulent  bubo  or  giving  pus  so  freely  hetero-in- 
oculable  as  chancroidal  pus.  The  latter  will  take  as  brilliantly,  when  ap- 
plied for  the  first  time,  upon  the  healthiest  tiller  of  the  soil,  as  upon  the 
most  cachectic  inmate  of  a  hospital. 

1  Keyes  (Van  Buren  and  Keyes) :  Genito-urinary  Diseases,  with  Syphilis.      New- 
York,  1874,  p.  478,  note. 

2  These  facts  were  communicated  to  me  by  a  gentleman  who  raises  bees. 


12  THE    VENEREAL  DISEASES. 

7.  A  syphilitic  chancre  may  be  auto-inoculated,  producing 
an  abortive  pustule,  an  auto-inoculable  ulcer,  or,  after  a  time,  a 
papule.     (Bidenkap,  Boeck,  and  many  others.) 

Generally,  the  old  rule  holds  good,  and  the  auto-inoculation  of  syphi- 
litic chancre  is  negative  in  its  result,  This  rule,  however,  has  many  ex- 
ceptions. The  syphilizers  and  Henry  Lee  have  abundantly  proved  that 
almost  any  syphilitic  chancre  may  be  rendered  freely  auto-inoculable  by 
rubbing  it  with  savin  ointment,  or  putting  tartar  emetic  on  it,  or  running 
a  seton  through  its  base — in  short,  by  rendering  its  suppuration  abundant 
and  creamy.  Here  it  is  evidently  the  pus  which  is  the  irritating  agent, 
and  not  the  secretion  of  the  chancre.  The  syphilitic  chancre  of  pure 
type  does  not  suppurate  at  all,  and  the  inoculation  of  its  serous  discharge 
does  not  produce  an  auto-inoculable  ulcer.  It  may  give  rise  to  an  abor- 
tive pustule,  as  may  any  local  traumatism  in  some  patients;  but  in  the 
vast  majority  of  trials  failure  will  be  absolute. 

There  is  nothing  strange,  again,  in  the  fact  that  such  chancres  worried 
into  suppuration  become  auto-inoculable,  since  the  pus  of  scabies,  the  pus 
of  ecthyma,  have  the  same  effect,  not  only  upon  syphilitics,  but  upon  some 
non-syphilitics.  And  finally,  the  occasional  production  of  a  hard  non- 
suppurating  papule  by  auto-inoculation  from  a  syphilitic  chancre  is  not 
very  strange.  If  the  inoculation  be  practised  very  early,  before  the  body 
is  saturated  with  syphilitic  poison,  another  chancre  is  the  result.  Just  as 
multiple  primary  inoculation  to  any  extent  upon  a  healthy  person  will 
produce  as  many  chancres  as  may  be  desired.  The  same  fact  is  noted 
clinically  in  cases  of  multiple  syphilitic  chancre. 

Later  on  the  papule,  or  the  papular  or  pustular  eruption  produced  by 
auto-inoculation  of  syphilitic  chancre,  is  simply  a  local  lesion,  a  local  ex- 
pression of  syphilis  called  out  upon  the  skin  by  a  traumatism.  It  is  well 
known  that  a  blister  upon  a  patient  with  latent  syphilis  may  call  out  an 
eruption.  Vaccination  may  do  the  same  thing.  I  have  frequently  seen 
local  prolonged  pressure  in  a  syphilitic  case  produce  a  local  papule  (e.  (/., 
from  the  shoe  about  the  ankle).  I  have  seen  the  wearing  of  an  indiffer- 
ent plaster  upon  the  skin  call  out  papules.  A  wound  will  sometimes  do  it. 
The  irritation  of  tobacco  notoriously  produces  mouth-lesions  in  syphilitic 
cases,  as  does  the  irritation  of  a  broken  tooth.  Lack  of  cleanliness  about 
the  anus  and  the  genitals  is  a  fertile  cause  of  condylomata  and  mucous 
patches.  If  then  all  sorts  of  irritants  acting  locally,  mechanical  and  chem- 
ical, upon  syphilitics,  can  produce  lesions,  why  may  not  the  scratch  of  a 
lancet,  or  the  inoculation  of  the  poison  of  syphilis,  as  contained  in  the  dis- 
charge of  the  primary  lesion,  do  as  well. 

8.  A  syphilitic  chancre,  by  hetero-inoculation  upon  a  healthy 
subject,  may  produce  nothing1,  or  an  abortive  pustule  not  fol- 
lowed by  syphilis. — Possibly  it  may  produce  an  ulcer  itself  auto-inocula- 
ble, which  gets  well  and  is  succeeded  by  an  indurated  ulcer  after  incubation 
followed  by  syphilis.  This  occurred  in  Danielssen's  case.   The  explanation  is 
simple.    The  patient  was  in  a  pus-forming  condition.    Any  pus  would  have 
done  as  well  as  the  pus  from  the  irritated  chancre  used.     An  auto-inocu- 
lable ulcer  resulted  at  once,  and  got  well.     Then  followed  true  syphilitic 
chancre  and  its  appropriate  sequence,  syphilis. 

The  cases  adduced  to  support  the  first  part  of  this  eighth  proposition 
are  meagre  in  number  (seven)  and  scant  in  detail.  Five  of  them  are  by 
the  anonymous  physician  of  the  Palatinate.  Of  these,  three  produced  pus- 
tules and  inflamed;  one  sloughed;  two  produced,  the  one  tubercles  (ulcera- 
ting)* tne  other  ulcers  after  thirty-six  and  forty-two  days'  incubation. 


CHANCROID.  13 

These  cases  are  difficult  to  explain.  In  the  first  three  the  hypothesis 
of  possible  error  as  to  the  nature  of  the  source  of  the  poison  might  be 
entertained,  or  previous  syphilis  in  the  inoculated  person,  or  some  possi- 
ble incapacity  on  the  part  of  the  one  inoculated  to  receive  the  poison. 
In  the  last  two  the  long  incubation  and  the  local  developments  make 
it  probable  that  they  both  acquired  true  syphilis  by  inoculation,  and  that 
general  symptoms  of  the  ordinary  kind  did  not  follow.  This  we  observe 
sometimes  clinically,  especially  in  the  case  of  women  who  get  syphilis 
from  their  husbands.  No  eruption  and  no  obvious  symptoms  follow  the 
infection  during  the  early  period,  while  subsequent  developments  confirm 
the  existence  of  syphilis.  Both  of  the  last  two  cases  here  referred  to 
were  women  (the  tenth  and  thirteenth  cases  of  the  anonymous  Palatinate). 

The  two  other  cases  of  syphilitic  inoculation  not  followed  by  syphilis 
were  those  of  Boeck  and  von  Rinecker.  The  former  was  the  case  of  a 
woman.  Large  superficial  pustules,  auto-inoculable  in  three  generations, 
followed,  and  no  general  symptoms.  This  looks  like  the  result  of  the  in- 
oculation of  an  irritated  syphilitic  chancre,  where  the  pus  alone  took  and 
the  syphilitic  poison  did  not.  The  chancroidal  pus  would  have  been  auto- 
inoculable  in  more  than  three  generations,  and  the  possibility  of  inocula- 
ting true  syphilis  negatively  has  no  stronger  theoretical  objection  than 
the  negative  inoculation  of  vaccine  virus — and  the  latter  is  well  known  to 
occur  very  often. 

Von  Rinecker's  case  was  that  of  a  boy  of  twelve,  who  was  inoculated 
from  a  primary  lesion.  The  incubation  was  twenty-seven  days,  the  re- 
sult a  tubercle  without  general  symptoms  afterward,  and  the  conclusion 
(for  it  was  a  take)  is  either  that  the  boy  had  inherited  syphilis,  or  was  one 
of  the  anomalous  cases  already  referred  to,  and  undoubtedly  occasionally 
encountered  clinically,  where  no  general  symptoms  followed  the  primary 
lesion  within  the  customary  period. 

These  cases  are  important  ones,  and  it  may  seem  like  begging  the 
question  to  try  to  theorize  them  away.  But,  even  granting  them  all  to  be 
what  their  authors  claim,  they  are  only  exceptions  among  so  many.  Ex- 
ceptions prove  rules  because  observers  are  not  omniscient,  and  certain  con- 
ditions which  seem  to  be  fulfilled  must  sometimes  fail  in  spite  of  all  our 
efforts  to  detect  the  whole  truth.  The  grouping  of  a  certain  series  of 
phenomena  following  certain  causes  constitutes  a  rule  in  the  eyes  of  all 
men,  and  no  rule  is  more  plentifully  upheld  by  examples  than  that  one 
which  states  that  the  inoculation  of  the  secretion  of  a  syphilitic  chancre 
upon  a  healthy  person  produces,  if  anything,  syphilis. 

Between  forty  and  fifty  cases  are  on  record  in  which  syphilitic  secre- 
tions have  been  experimentally  inoculated  upon  healthy  persons.  Among 
these,  seven  are  exceptions,  the  rest  follow  the  rule.  Confrontations  cer- 
tainly number  thousands,  and  syphilis,  when  traced  up,  is  always  found 
to  be  derived  from  syphilis  in  another.  It  does  not  arise  de  novo. 

Vaccine  virus  is  well  known  to  be  contagious,  yet  no  one  is  astonished 
when  its  inoculation  sometimes  proves  abortive.  In  the  epidemics  of  vac- 
cinal  syphilis,  only  a  certain  proportion  of  the  children  vaccinated  get 
syphilis.  Even  chancroidal  virus  (much  more  irritating  and  virulent  than 
the  syphilitic  poison)  occasionally  fails  to  take,  probably  because  inocula- 
tion is  not  properly  performed,  possibly  on  account  of  an  idiosyncrasy  of 
the  patient.  Hiibbenet,1  of  Kiew,  reports  two  cases  where  he  uniformly 
failed  to  get  a  positive  result  from  the  inoculation  of  chancroidal  pus. 


Die  Beobachtung  und  das  Experiment  in  der  Syphilis.     Leipsic,  1858,  p.  11. 


14  THE    VENEREAL   DISEASES. 

I  have  now  a  patient  under  treatment  who  acquired  his  disease  from 
a  woman  with  whom  a  personal  friend  consorted  a  few  moments  later  and 
received  no  harm  therefrom,  and  instances  of  this  sort  are  by  no  means 
uncommon. 

The  blood  of  syphilis  is  known  to  produce  a  syphilitic  chancre  by  in- 
oculation, and  this  proposition  is  not  at  all  invalidated,  because  seventeen 
out  of  the  twenty-three  reported  cases  of  inoculation  of  syphilitic  blood 
gave  negative  results.  The  poison  was  doubtless  more  dilute  in  these 
cases,  or  the  inoculation  improperly  performed. 

If  the  inoculation  of  syphilitic  virus  upon  an  uninfected  person  may 
prove  abortive — and  the  inoculation  of  indifferent  purulent  secretions  upon 
some  people  may  give  rise  to  ulcers,  auto-inoculable  in  generations — then 
these  exceptional  cases  lose  all  their  value,  in  so  far  as  they  controvert 
the  doctrine  of  two  poisons:  one,  sui  generis,  for  chancroid;  the  other, 
specific,  for  syphilis. 

9.  Secretions  derived  from  auto-inoculable  ulcers,  which  lat- 
ter have  been  originated  from  pus  first  taken  from  an  irritated 
syphilitic  chancre,  may  by  hetero-inoculation  produce  an  auto- 
inoculable  ulcer,  not  followed   by  syphilis. — This  assertion  rests 
upon  Bidenkap's  case,  which  has  already  been  discussed  and  a  possible 
solution  offered  (p.  4). 

10.  The  pus  from  many  of  the  later  lesions  of  syphilis  is  auto- 
inoculable,  producing  auto-inoculable  ulcers  (upon  the  syphilitic 
patient)  just  as  other  indifferent,  non-poisonous  pus  -will  produce 
a  similar  result,  more  or  less  marked  in  degree,  according  to  the 
quality  of  the  pus  (Pick,  Melchior  Robert,  Koebner,  Boeck,  Bidenkap, 
Clerc,  Fournier,  Lee,  and  others). — What  has  already  been  said  in  this 
chapter  covers  this  point;  no  further  explanation  is  necessary. 

11.  Vaginal  secretions,  taken  from  syphilitic  women  having 
no  ulceration  of  the  genitals  and  auto-inoculated,  produce  auto- 
inoculable  ulcers  upon  these  women  resembling   chancroids 
(Morgan,  of  Dublin). — The  same  reasoning  in  explanation  applies  here  as 
that  alluded  to  under  head  10. 

12.  A  mixed  chancre  (Rollet)  exists  possessing  the  physical 
qualities  found  in  ulcers  produced  by  both  of  the  poisons. — It 
will  be  described  later.     It  exists  clinically.     It  has  been  produced  ex- 
perimentally.    (Melchior  Robert,  Lindwurm,  Basset,  Laroyenne.) 

Discussions  upon  the  existence  of  one  or  two  poisons  for  the  different 
sores  will  doubtless  never  cease.  They  are  of  value  to  the  cause  of  sci- 
ence, but  unfortunate  if  their  conclusions  lead  to  the  practice  of  treating 
all  venereal  sores  alike. 

One  may  readily  accept  without  damage  the  doctrine  that  there  is  only 
one  poison — that  poison  syphilis,  while  chancroid  is  only  a  common  ulcer 
auto-inoculable,  but  not  in  any  sense  poisonous.  This  conclusion  cannot 
lead  to  practical  harm.  The  doctrine  which  intimates  that  there  is  but 
one  poison — syphilis,  and  that  that  poison  produces  sometimes  chancroid, 
sometimes  syphilitic  chancre,  must  be  pernicious  in  its  results,  and  lead 
to  years  of  needless  dosing  in  the  case  of  patients  who  require  only  local 
treatment. 


CHAPTER  II. 

CHANCROID. 

DESCRIPTION  OF  ITS  SPECIAL  FEATURES  AND  OF  THE  VARIATIONS  TO  WHICH 

THEY  ARE  LIABLE. 

Pathological  Histology  of  Chancroid;  Comparative  Histology  of  Syphilitic  Chancre  and  of 
Chancroid. — Transmission  of  Chancroid  to  Animals. — Transmission  of  True  Syphi- 
lis to  Animals. — The  Relative  Frequency  of  Chancroid. — The  Methods  of  Chancroid- 
al  Contagion,  Direct  and  Mediate. — The  Inoculation  of  Chancroid. — Auto-inocula- 
tion and  Hetero-inoculation. — Case  illustrating  the  Diagnostic  Value  of  Auto-inocu- 
lation.— Inoculation  in  Generations. — How  to  Practise  Experimental  Inoculation. 
— The  Incubation  of  Chancroid  ;  Variation  in  Incubation.  — Course  of  Chancroid ; 
Period  of  Increase  ;  Stationary  Period;  Period  of  Repair ;  Variations  in  Course. — 
Situation  of  Chancroid;  Variation  in  Situation. — Number  of  Chancroids. — Form 
of  Chancroid  ;  Variations  in  Form. — Follicular  Chancroid. — Subjective  Symptoms 
of  Chancroid. — Condition  of  the  Base. — Duration  of  Chancroid;  Variations  in 
Duration. — Cicatrix  of  Chancroid. 

Pathological  histology  of  chancroid. — The  minute  structure  of 
chancroid,  as  revealed  by  the  microscope,  presents  nothing  special.  That 
quality  which  constitutes  the  virulence  of  chancroid  does  not  become  evi- 
dent by  being  magnified,  nor  does  it  impress  any  property  upon  the  elements 
composing  the  ulcer  peculiar  to  itself.  Many  efforts  have  been  made  to 
establish  points  of  comparative  diagnosis,  by  the  aid  of  the  microscope,  be- 
tween chancroid  and  chancre,  but  without  any  success  that  can  be  practi- 
cally utilized.  Biesiadecki  found  v?ry  little  difference.  The  tissues  of 
the  cutis  and  the  lower  cells  of  the  epidermis  are  swollen  in  both  instances, 
the  adventitia  of  the  blood-vessels  is  said  to  be  more  dense  in  syphilitic 
chancre  and  the  walls  of  the  capillaries  thickened  (Biesiadecki),  the  lumen 
of  the  thick-walled  vessels  becomes  diminished.  The  tissues  in  and  around 
the  ulcer  in  both  cases  are  filled  with  nucleated  cells  crowded  together  in  the 
meshes  formed  by  separation  of  the  bundles  of  connective  tissue.  These 
cells  soon  render  the  line  between  the  cutis  vera  and  the  mucous  layer  of 
the  epidermis  indistinct,  and  the  epithelial  layer  becomes  thinner.  Follow- 
ing this,  ulceration  may  ensue. 

Verson  believed  the  induration  in  syphilitic  chancre  to  be  due  to  new 
formation  of  connective  tissue;  but  the  tissue  is  not  peculiar  in  any 
way.  Buhl  found  the  blood-vessels  enlarged  and  their  coats  infiltrated 
in  chancroid  as  well  as  in  chancre.  Auspitz  and  Unna1  (the  latest  in  the 
field)  attempt  to  make  clear  the  characters  distinguishing  syphilitic  chan- 
cre from  chancroid;  but  they  do  not  succeed  in  doing  more  than  the  un- 
aided eye  had  done  before,  and  certainly  point  out  nothing  pathognomo- 

1  Die  Anatomic  der  syphilitiechen  initial-sclerose.  Separat  abdruck  aus  der  Viertel- 
jahresschrift  f.  Derm  u.  Syph.  Wien,  1877,  pp.  161. 


16  THE    VENEREAL   DISEASES. 

nic — nothing  which  could  be  relied  upon  to  help  the  clinical  inquirer,  even 
if  he  cut  out  the  initial  lesion  to  study  it  up  in  a  case  of  doubt. 

They  confirm  the  thickening  of  the  adventitia  of  the  vessels  noted  by 
Biesiadecki  (and  frequently  found  elsewhere  by  other  observers).  They 
speak  of  the  cellular  infiltration  and  of  the  hypertrophy  of  fibrillary  con- 
nective issue.  This  fibrillary  material  Unna1  says  is  pure  collagen.  He 
thinks  this  gives  its  hardness  to  syphilitic  chancre,  that  it  is  most  marked 
in  the  adventitia  of  the  individual  vessels.  He  believes  that  the  starting- 
point  of  the  disease  is  in  the  vasa  vasorum,  endothelial  changes  coming 
later.  Where  there  are  no  vasa  vasorum  the  adventitia  is  the  point  of 
origin  of  the  process.  The  lymph-spaces  disappear  in  the  fibrous  felting 
of  the  skin,  while  round-celled  infiltration  is  general.  Frequently  there  is 
absence  of  true  ulceration  and  very  often  there  is  actual  preservation  of 
the  epidermis  over  the  lesion,  which  sometimes  even  increases  in  thick- 
ness and  grows  downward,  sending  off  lateral  shoots. 

In  all  this  description  there  is  surely  nothing  which  may  not  be  imi- 
tated by  other  processes  not  syphilitic.  Nothing  specific  has  been  found, 
and  most  of  these  facts  were  presumed  before  the  microscope  was  brought 
to  bear  upon  these  special  lesions,  for  true  chancroid  is  an  ulcer,  true  syph- 
ilitic chancre  often  is  not. 

Transmission  to  animals. — In  1844,  Auzias  Turenne  succeeded  in 
producing  a  number  of  positive  takes  upon  different  animals  by  inoculat- 
ing them  with  chancroidal  pus.  Robert  de  Weltz,  six  years  later,  took  pus 
from  chancroids  which  he  had  produced  by  inoculation  upon  a  cat  and 
a  monkey,  and  inoculated  his  own  arm  four  times,  with  success.  Turenne 
inoculated  chancroidal  pus  in  generations  upon  animals,  and  found  that 
ulcers  soon  failed  to  be  produced.  The  peculiar  virulence  of  chancroid, 
it  appears,  does  not  long  continue  upon  the  soil  furnished  by  the  tis- 
sues of  the  lower  animals — a  rather  peculiar  fact,  when  it  is  remem- 
bered with  what  ease  profuse  suppuration  is  set  up  in  some  of  them  (the 
rabbit).  Turenne,  on  account  of  his  discovery  that  the  virulence  of 
chancroid  died  out  by  repeated  auto-inoculation,  and  believing  that  chan- 
croid was  syphilitic — for  he  was  a  unicist — established  the  doctrine  of  syph- 
ilization,  an  attempt  to  cure  syphilis  by  repeated  and  exhaustive  inocula- 
tion of  chancroid — a  doctrine  which  with  some  modifications  exists  even 
at  the  present  day,  in  spite  of  the  death  of  its  sturdy  advocate,  Boeck. 
Turenne  was  consistent  in  his  practice  with  his  theory.  He  made  no 
public  confession  of  what  he  was  doing,  but  he  undoubtedly  syphilized 
his  own  body,  which  at  his  death  is  reported  to  have  been  covered  with 
scars. 

In  the  light  of  modern  inoculations  it  may  be  contended  that  the  auto- 
inoculable  sores  produced  upon  animals  were  not  chancroids,  but  ulcers — 
not  poisonous,  auto-inoculable  in  generations,  like  the  ulcers  produced 
upon  a  cachectic  person  by  the  inoculation  of  acne-pus;  and  the  fact  that 
Weltz  produced  ulcers  upon  himself  by  re-inoculating  this  pus  from  the 
animal  back  to  himself  would  not  in  the  least  oppose  such  a  conclusion. 
Two  recorded  circumstances,  however,  carry  conviction  that  the  poison  of 
chancroid  is  transmissible  to  animals,  develops  there,  and  may  be  carried 
back  again  and  successfully  inoculated  in  man.  The  two  cases  are  those 
of  Ricordi  and  Diday :  the  former  produced  a  chancroidal  bubo  (a  virulent, 
not  a  simple  bubo),  in  a  rabbit,  while  Diday,  in  1851,  by  inoculating  his 

1  Vierteljahresschrift  f.  Derm.  u.  Syph.     1878,  p.  543. 


CHANCROID.  17 

own  penis  with  pus  derived  from  an  ulcer  which  he  had  originated  by 
inoculating  chancroidal  pus  upon  the  ear  of  a  rabbit,  produced  a  chancroid 
upon  himself.  His  chancroid  soon  became  phagedenic,  and  was  attended 
by  suppurating  (not  virulent,  however)  bubo. 

Up  to  the  present  time  a  distinguishing  mark  between  the  poisons, 
claimed  by  the  advocates  of  two  poisons,  has  been  that  chancroid  could 
be  transmitted  to  animals,  while  syphilis  could  not.  Numerous  attempts 
at  inoculating  syphilis  had  been  made,  but  they  invariably  failed  to  de- 
monstrate that  any  animal  could  acquire  syphilis.  Depaul's  syphilitic 
monkey  and  the  cachectic  syphilitic  cat  of  Vernois  have  not  been  regard- 
ed as  more  than  effects  of  a  vivid  imagination.  It  may  be,  however,  that 
the  judgment  of  the  profession  on  this  point  also  must  be  modified  if  the 
recent  discovery  made  by  an  eminent  scientist  is  confirmed  by  future  in- 
vestigation. 

At  a  meeting  of  naturalists '  at  Cassel,  in  1878,  Klebs  announced  the 
discovery  of  a  parasite,  the  cause  of  syphilis.  The  microscope  showed 
him  certain  slowly  moving  little  rods  in  freshly  extirpated  Hunterian 
chancres.  From  these  by  cultivation  he  produced  a  plant  composed  of 
stationary  rods  terminating  in  spiral  prolongations  of  jointed  rods.  By 
inoculating  these  cultivated  helikomonads,  as  he  calls  the  plants,  upon 
an  ape,  he  produced  symptoms  resembling  syphilis.  By  inserting  under 
the  skin  of  another  ape  a  piece  of  a  syphilitic  chancre,  he  claims  to  have 
produced  symptoms  upon  the  integument,  in  the  mouth,  the  bones  of  the 
skull,  meninges  of  the  brain,  etc. — tissue-changes  identical  with  those  pro- 
duced by  syphilis  in  man,  while  from  the  blood  of  this  ape  he  cultivated 
a  plant  resembling  that  inoculated  upon  the  first  ape. 

These  new  discoveries  will  doubtless  be  at  once  tested.  Should  they 
prove  accurate,  another  distinction  between  chancroid  and  syphilitic  chan- 
cre, formerly  relied  upon  by  the  dualists,  will  have  disappeared. 

The  relative  frequency  of  chancroid. — The  poison  of  chancroid  is 
more  virulent  than  that  of  syphilitic  chancre;  it  takes  more  easily,  as  proved 
by  the  number  of  negative  results  attending  inoculation  of  syphilitic 
blood  upon  healthy  persons,  and  the  free  auto-  and  hetero-inoculability 
of  chancroid.  Chancroid  may  recur  indefinitely  in  the  same  individual. 
Hence,  it  is  to  be  expected  that  chancroid  will  be  found  more  frequently 
than  chancre,  and  all  statistics  drawn  from  hospital  experience  prove  this 
to  be  the  case.  Puche's  statistics  of  ten  thousand  from  the  Midi  Hospital 
credit  nearly  a  clear  eighty  per  cent,  of  the  cases  to  chancroid,  and  the 
statistics  of  the  Plymouth  Naval  Hospital  give  seventy  per  cent.  The 
practitioner  among  respectable  people,  however,  is  astonished  at  the 
small  number  of  chancroids  he  encounters.  Herpetic  troubles  are  cer- 
tainly more  common  than  anything  else — taking  the  world  at  large;  and 
Fournier,  out  of  three  hundred  and  thirty-four  cases  in  his  own  private 
practice,  only  encountered  eighty-two  chancroids.  The  statistics  of  Four- 
nier, quoted  by  Lancereau  (2d  ed.,  p.  82),  and  doubtless  covering  hospital 
cases,  credits  chancroid  with  a  little  over  sixty-six  per  cent,  of  the  whole 
number  reported. 

The  conclusion  is,  as  Fournier  pointed  out,  that  the  greater  care  and 
neatness  exercised  in  the  higher  classes  protects  them  in  a  measure  from 
chancroid,  but  offers  no  gurantee  against  infection  by  the  seemingly  less 
formidable  primary  lesion  of  true  syphilis.  The  conclusion  becomes 
especially  obvious  on  considering  the  fact  that  mucous  patches,  which 

1  Allg.  Wien.  med.  Zeitung,  Oct.  15,  1878,  p.  418. 


18  THE    VENEREAL   DISEASES. 

may  lie  concealed  high  up  in  the  vagina,  and  last  for  months  at  a  time, 
are  as  capable  of  communicating  syphilis  as  is  the  true  syphilitic  chancre. 

The  manner  of  contagion. — The  chancroidal  virus  is  not  volatile. 
Chancroid  is  only  possible  by  contact  of  chancroidal  pus  with  a  surface 
deprived  of  epithelium.  Cullerier's  famous  experiments  show  this.  Two 
women  were  found  with  no  lesion  of  the  vagina  in  either  case.  The  vagi- 
nal secretions  were  auto-inoculated  without  effect.  Chancroidal  pus  was 
placed  in  the  vagina,  where  it  remained  thirty-five  minutes  in  one  case, 
nearly  an  hour  in  the  other.  Then  the  contents  of  the  vagina  in  each  case 
were  successfully  auto-inoculated.  In  both  the  vagina  was  washed  with 
an  astringent  solution,  and  in  neither  did  any  vaginal  ulcer  follow. 

The  surgeon  knows  well  that,  so  long  as  there  are  no  cracks  in  his  fin- 
gers, he  may  handle  chancroidal  pus  with  impunity. 

There  is  one  exception  to  this  rule,  namely,  where  chancroidal  pus  is 
placed  upon  healthy  epithelium,  remains  there  undisturbed,  erodes  the 
epithelium  by  virtue  of  its  acridity,  and  thus  prepares  a  way  for  the  ab- 
sorption of  the  virus.  In  this  way  chancroids  of  long  incubation  are  ex-. 
plained;  and  in  a  similar  way  the  follicular  chancroid,  in  which  a  few 
leucocytes  bearing  chancroidal  virus  are  believed  to  be  rubbed  into  the 
mouth  of  a  healthy  follicle,  and  thence  gradually  to  erode  a  way  by  which 
contagion  becomes  possible  through  the  thin  wall  of  the  follicle  under- 
neath the  surface  of  the  superficial  epidermis.  The  period  of  incubation 
in  this  case  is  also  generally  long. 

The  methods  of  contagion  are  two,  direct  and  mediate. 

Direct  contagion. — In  direct  contagion  the  source  supplying  the  pus 
and  the  part  inoculated  come  into  direct  contact.  This  is  the  usual  way. 
In  sexual  intercourse,  when  a  chancroid  upon  an  individual  inoculates  a 
portion  of  overlying  contiguous  integument,  when  a  fissure  on  the  physi- 
cian's finger  becomes  contaminated  while  practising  the  vaginal  touch — 
these  are  all  instances  of  direct  contagion. 

Mediate  contagion. — This  means  that  there  is  an  intermediate  car- 
rier of  the  pus  which  receives  it  from  its  source  and  deposits  it  where  it 
finally  takes  root.  The  vagina  may  be  the  medium  of  contagion  receiving 
the  pus  from  one  man  to  give  it  up  to  another  immediately  without  itself 
becoming  contaminated.  Cullerier's  cases  prove  the  possibility  of  this — 
but  it  must  be  very  rare.  The  prepuce  may  play  a  similar  intermediate 
part.  The  lancet  of  the  surgeon  gives  rise  to  mediate  contagion  in  cases 
of  inoculation. 

Inoculation  of  chancroid. — The  pus  of  chancroid  remains  virulent 
until  the  ulcer  is  healed,  but  decreases  in  virulence  toward  the  end.  A 
single  corpuscle  is  believed  to  be  capable  of  producing  a  chancroid  by  in- 
oculation. Frozen  and  corked  up  in  bottles,  the  pus  retains  its  virulence 
for  a  long  time  (Boeck).  Boiling  heat,  acids,  alkalies,  corrosive  subli- 
mate, alcohol,  decomposition — all  destroy  the  virulence  of  the  pus.  Boeck 
believes  that  dried  pus  is  inert;  Sperino  taught  the  contrary.  Inocula- 
tion is  spoken  of  under  two  heads — auto-  and  hetero-inoculation. 

Auto-inoculation  is  the  inoculation  of  the  patient  with  the  secretion 
of  the  chancroid  he  himself  bears.  This  is  generally  effected  purposely  as 
a  test  by  the  surgeon.  It  may  take  place  by  contact  of  adjacent  surfaces. 
In  such  a  case  it  is  called  spontaneous  auto-inoculation.  Auto-inocula- 
tion as  a  diagnostic  test  is  not  so  commonly  employed  now  as  formerly. 
As  a  test  it  is  thought  to  be  deceptive,  since  so  many  other  kinds  of  pus 
produce  ulcers  upon  some  persons.  These  latter  ulcers  are  not  chancroids, 
but  they  secrete  pus  and  are  apt  to  deceive.  Chancroid,  moreover,  is  so 


CHANCROID.  19 

•  well  understood  now  to  be  harmless  and  unproductive  of  syphilis,  that  in 
cases  of  doubt  it  may  be  observed  for  a  time,  or  treated  at  once,  as  the  sur- 
geon chooses,  without  calling  for  any  internal  medication  or  disturbing  the 
patient's  peace  of  mind  in  the  future,  should  no  symptoms  follow. 

Yet  auto-inoculation  is  still  an  excellent  resource  in  many  cases,  the 
frank  take  of  the  true  ulcer  being  very  characteristic  and  always  easy  to 
obtain  upon  a  fresh  subject — a  fact  which  cannot  be  affirmed  to  the  same 
extent  about  any  other  kind  of  pus.  In  the  following  case,  on  one  occa- 
sion it  proved  of  great  value. 

In  midsummer,  a  thin  apothecary  came  to  me  with  an  oval  ulcerated 
fissure  at  the  edge  of  a  somewhat  tight  prepuce.  This  prepuce  he  pulled 
back  twenty  times  a  day  in  order  to  inspect  the  ulcer  better.  His  wife 
was  away.  He  was  greatly  frightened,  and  in  such  a  state  of  depression 
that  he  could  neither  eat  nor  sleep.  The  fissure  was  several  weeks  old, 
suppurating  only  moderately.  It  did  not  look  very  virulent,  and  I  as- 
sured the  man  that  his  fears  and  his  manipulations  were  keeping  the  ulcer 
in  existence,  and  that  it  would  get  well  if  let  alone.  Weeks  passed,  how- 
ever, and  it  did  not  get  well  under  simple  medication.  It  did  not  spread 
and  there  was  no  bubo.  I  sent  him  for  an  opinion  to  a  number  of  sur- 
geons of  eminence,  and  all  agreed  that  the  ulcer  was  a  simple  one,  kept  up 
by  the  weakness  and  anaemia  of  the  patient,  and  the  position  of  the  sore. 

Finally  the  patient's  wife  was  about  to  return  and  he  was  convinced 
of  the  simple  nature  of  his  sore,  which  had  now  lasted  many  weeks  un- 
changed. I  inoculated  him  twice  on  the  forearm,  mainly  as  an  experi- 
ment. In  three  days  the  inoculated  points  became  two  brilliant  typical 
chancroids. 

The  wife  was  detained  away  by  a  telegraphic  excuse,  and  a  single 
cauterization  with  fuming  nitric  acid  cured  all  three  ulcers  promptly,  the 
character  of  the  ulcer  on  the  prepuce  changing  immediately  on  the  fall 
of  the  slough. 

Inoculation  in  generations  is  repeated  inoculation  of  pus  from  one 
source,  taking  the  supply  for  each  fresh  sore  from  the  one  last  produced, 
until  the  pus  no  longer  takes  on  the  same  individual.  Fresh  pus  derived 
from  a  new  parent  source  may  now  start  a  new  process  of  inoculation  in 
generations  upon  the  same  patient,  and  then  again  fresh  pus,  until  at 
last  the  skin  will  no  longer  take,  and  abortive  pustules  at  best,  or  noth- 
ing results,  from  any  fresh  inoculations.  This  much  syphilizers  have 
proved,  and  the  process  they  have  adopted  is  the  one  just  described. 

After  a  patient  has  been  "  syphilized,"  as  it  is  called,  and  has  a  rest, 
he  may  be  syphilized  again,  since  the  skin  recovers  from  its  immunity. 

Thus  it  appears  there  is  a  limit  to  auto-inoculation,  but  no  one  knows 
how  long  one  would  continue  susceptible  to  inoculation  were  only  one 
chancroid  created  at  a  time.  Lindmann  certainly  reached  twenty-seven 
hundred,  and  was  still  succeeding  when  last  reported;  and  practically  (cer- 
tainly for  clinical  purposes),  it  may  be  affirmed  that  there  is  no  limit  to 
to  the  susceptibility  of  an  ordinary  individual  to  chancroidal  virus.  He 
may  take  as  often  as  he  is  exposed. 

The  method  of  inoculation  of  syphilizers  is  perhaps  the  best.  A  mi- 
nute portion  of  pus  is  taken  on  the  point  of  a  lancet,  and  held  at  right 
angles  to  the  skin  at  the  point  selected  for  inoculation.  The  tip  of  the 
lancet  is  made  to  penetrate  just  below  the  epidermis,  rotated,  withdrawn, 
and  its  point  is  wiped  off  upon  the  minute  wound.  Extensive  scarifica- 
tions are  to  be  avoided,  since  they  produce  large,  irregular  sores,  and  not 
the  round  typical  chancroid. 


20  THE   VENEREAL   DISEASES. 

The  point  most  suitable  for  auto-inoculation  for  diagnostic  purposes 
is  the  breast  below  the  nipple.  Here  the  skin  resists  a  take.  A  true 
chancroid  will  undoubtedly  always  take  here,  but  the  resulting  sore  is 
not  apt  to  be  troublesome,  and  phagedaena  is  almost  unheard  of  in  this 
region.  The  head  and  face  are  peculiarly  bad  soil  for  a  take,  and  would 
be  proper  sites  for  auto-inoculation,  except  for  the  fact  that  severe  chan- 
croids do  sometimes  occur  in  these  regions,  and  the  resulting  scar  is  dis- 
figuring. Chancroids  have  been  repeatedly  produced  on  the  face  by  auto- 
inoculation,  and  the  ancient  notion  that  all  venereal  ulcers  on  the  face 
are  necessarily  syphilitic  is  not  accurate.  The  upper  and  outer  part  of 
the  thigh  is  also  a  good  site  for  auto-inoculation  for  diagnostic  purposes. 
It  is  out  of  the  way  of  the  absorbents,  and  not  likely  to  inflame  exces- 
sively, or  to  become  complicated  in  this  region.  Over  the  insertion  of 
the  deltoid  in  the  arm  is  another  good  site. 

Hetero-inoculation  is  the  inoculation  of  pus  from  one  patient  to 
another,  as  practised  by  syphilizers.  Chancroid,  as  found  clinically,  is  also 
the  result  of  hetero-inoculation. 

Incubation  of  chancroid  signifies  the  time  which  elapses  between 
contact  with  the  poison  and  the  appearance  of  the  ulcer.  If  we  had  mi- 
croscopic eyes,  we  should  recognize,  probably,  that  changes  in  the  tissues 
commence  immediately  upon  contact  of  the  virus  with  a  denuded  surface. 
As  it  is,  by  the  end  of  twenty-four  hours,  the  inoculated  point  is  distinctly 
red,  during  the  second  or  third  day  a  pustule  forms,  and  generally  by  the 
third  day,  if  the  pustule  be  broken,  a  fully  formed  minute  chancroid,  pos- 
sessed of  all  the  characters  of  the  typical  ulcer,  is  found,  with  its  abrupt 
margin,  suppurating  floor,  soft  base,  pink  areola,  etc.  Boeck  says  that  the 
pus  is  contagious,  taken  from  the  pustule  on  the  third  day.  Clinically  the 
same  holds  good,  and  the  incubation  of  chancroid  is  placed  at  two  or  three 
days,  very  rarely  longer.  When  first  found  by  the  patient,  it  is  generally 
already  an  ulcer  or  an  exulcerated  fissure.  Sometimes  it  is  a  pustule. 

Variation  in  incubation. — Clinically,  incubation  may  reach  a  week, 
possibly  ten  days.  This  occurs  in  cases  of  follicular  chancroid,  or  when 
the  pus  has  been  deposited  upon  unbroken  epithelium  and  has  to  erode 
its  way  through  before  a  take  can  be  effected.  Sometimes  the  ulcer  is 
not  found  by  an  unobservant  patient  until  many  days  have  elapsed,  because 
it  has  caused  no  pain,  and  has  not  attracted  attention.  Such  a  patient, 
on  finding  a  large  ulcer  by  accident,  will  think  it  impossible  that  such  a 
sore  could  have  escaped  his  attention  had  it  existed  the  day  before,  and 
he  will  declare  that  it  has  just  appeared,  and  resent  the  suggestion  that 
he  has  overlooked  it. 

Course  of  chancroid. — Uncomplicated  chancroid  tends  to  run 
through  three  definite  periods:  the  period  of  increase,  the  stationary  pe- 
riod, the  period  of  repair. 

.Period  of  increase. — This  lasts  one  or  two  weeks,  occasionally  a  lit- 
tle longer.  The  ulcer  increases  in  size,  preserving  absolutely  its  charac- 
teristic features.  It  generally  stops  when  it  reaches  about  one-fourth  of 
an  inch  in  diameter,  but  may  rapidly  spread  to  the  diameter  of  an  inch  or 
more. 

Stationary  period. — During  about  two  weeks,  sometimes  longer  if 
unmolested,  the  ulcer  tends  to  remain  absolutely  stationary,  not  undergo- 
ing any  change  that  can  be  appreciated.  In  persons  not  very  susceptible 
to  the  poison,  very  often  toward  the  end  of  a  course  of  syphilization  the 
stationary  period  does  not  exist,  but  repair  sets  in  after  the  ulcer  has 
reached  a  certain  size. 


CHANCROID.  21 

Period  of  repair. — This  comes  on  gradually.  The  floor  of  the  ulcer 
grows  more  pink  and  even, "the  edges  become  sloping,  and  cicatrization 
advances  slowly  from  the  circumference  toward  the  centre. 

Variations  in  course. — Many  of  the  deviations  in  the  typical  fea- 
tures of  chancroid  lead  to  variations  in  its  course.  They  will  be  consid- 
ered under  the  heads  of  relapse,  inflammation,  phagedasna,  gangrene. 

Situation  of  chancroid. — Chancroid  is  commonly  found  in  the  fur- 
row behind  the  corona  glandis  on  the  penis  of  the  male,  and  posteriorly  in 
the  fourchette  of  the  vagina  of  the  female.  A  natural  pocket  exists  at 
these  points,  the  epithelium  is  soft  there,  and  abrasions  not  uncommon, 
especially  along  the  side  of  the  frenum  in  the  male.  In  this  situation 
chancroid  frequently  ulcerates  its  way  beneath  the  frenum,  and  some- 
times perforates  the  urethra.  The  pus  naturally  gravitates  to  the  four- 
chette in  the  female. 

Variation  in  situation. — No  portion  of  the  body  is  exempt  from  in- 
oculation by  chancroid.  The  head  and  face,  once  considered  exempt,  has 
been  proved  not  to  be  so  by  numerous  syphilizers.  R.  W.  Taylor  has 
shown  that,  clinically,  chancroid  upon  the  head  may  be  of  exceptional  se- 
verity, and  three  very  interesting  cases  of  phagedenic  chancroid  of  the 
face  are  reported  by  Profeta,  of  which  the  first  is  especially  striking. 
A  serpiginous  chancroid,  lasting  two  years,  had  occasioned  extensive 
ravages  upon  the  face.  The  patient  had  inoculated  his  own  hand 
while  handling  the  sore,  and  Profeta  inoculated  himself  from  the  ulcer 
with  positive  result.  Hygiene,  with  local  stimulants,  cured  the  ulcer 
promptly. 

Chancroids  are  common  anywhere  upon  or  within  the  prepuce  in  the 
male,  the  ostium  vaginas  in  the  female.  At  the  orifice  of  the  urethra  they 
are  encountered  in  both  sexes,  and  they  are  apt  to  be  sluggish  in  their 
course  in  these  situations.  Chancroid  deep  in  the  urethra  of  the  male  is 
very  rare.  They  are  also  rare  deep  in  the  vagina,  but  have  been  observed 
upon  the  neck  of  the  uterus,  and  (Delmas  and  Combal)  within  the  uterus. 
The  anus  and  rectum  are  the  seat  of  chancroid  either  communicated  a 
preposterd  venere,  or,  in  the  female,  due  to  spontaneous  auto-inoculation, 
the  chancroidal  pus  trickling  down  over  the  anus  from  the  vaginal  four- 
chette as  the  patient  lies  upon  her  back.  The  fingers  of  the  surgeon  and 
of  the  patient  with  chancroid  are  apt  to  become  poisoned  accidentally. 

Number  of  chancroids. — Clinically,  chancroid  is  multiple  among 
hospital  and  dispensary  patients,  often  solitary  in  the  better  classes,  who 
are  more  scrupulously  clean.  If  multiple  abrasions  have  been  simultane- 
ously poisoned  during  sexual  intercourse,  the  resulting  ulcers  will  natu- 
rally be  multiple  from  the  first.  Often,  however,  but  one  sore  comes  out 
at  first,  and  this  by  spontaneous  auto-inoculation  produces  many  similar 
sores  in  the  immediate  neighborhood.  Around  the  anus,  and  at  the  mar- 
gin of  the  prepuce,  chancroid  is  nearly  always  multiple.  When  chancroid 
is  multiple  from  the  first,  the  numerous  ulcers  are  apt  to  be  small.  Single 
chancroid  is  generally  larger.  Sperino  found  in  practising  syphilization 
that,  the  greater  the  number  of  points  of  simultaneous  inoculation,  the 
smaller  was  the  relative  size  of  the  resulting  ulcers.  He  utilized  this  dis- 
covery in  lessening  the  size  of  the  scars  of  his  patients,  whom  he  syphi- 
lized. 

Form  of  chancroid. — The  typical  chancroid  has  been  described 
(p.  2).  It  is  round,  or  may  be  unsymmetrically  irregular  on  account  of 
the  situation,  or  the  shape  of  the  abrasion  or  fissure  inoculated,  or  on 
account  of  the  running  together  of  several  chancroids  of  different  sizes, 


22  THE   VENEREAL   DISEASES. 

in  which  case  its  border  is  described  by  segments  of  uneven  circles.     Mul- 
tiple chancroid  of  the  anus  is  stellate. 

Variations  in  form. — Instead  of  being  an  open  ulcer,  chancroid 
sometimes  remains  scabbed  over.  The  thick  pus  dries  up  on  the  surface, 
but  continues  to  be  formed  beneath  the  scab,  from  the  sides  of  which  it 
oozes  under  pressure.  It  advances  by  the  formation  of  new  rings  of  pus 
under  the  epidermis  around  the  old  scab,  and  generally  has  a  livid  areola 
outside  of  all.  It  resembles  rupia,  is  by  no  means  common,  and  is  called 
ecthymatous  chancroid.  Lift  off  the  crust  in  such  a  case,  and  the  charac- 
teristic ulcer  will  be  revealed. 

Follieular  chancroid. — In  this  form  of  chancroid,  infection  takes 
place  through  the  mouth  of  a  healthy  follicle,  into  which  a  few  pus-cells 
have  been  rubbed.  It  is  a  clinical  chancroid,  and  cannot  be  produced  ar- 
tificially. Inoculation  takes  place  beneath  the  plane  of  the  surface  epi- 
dermis, and  if  the  latter  happens  to  be  tough,  it  retains  its  integrity  for 
a  considerable  period  after  the  tissues  beneath  it  have  been  melted  down 
into  pus. 

Therefore,  when  seen  it  is  a  large  acuminated  pustule,  often  covered 
by  a  peculiarly  dense  epidermis.  The  lesion  varies  in  size,  and  is  full  of 
thick  pus.  Suppuration  tends  to  spreads  peripherally  beneath  the  epi- 
dermis until  the  latter  has  broken.  By  cutting  away  the  thickened  epi- 
dermis the  typical  chancroid  is  disclosed.  The  incubation  of  follicular 
chancroid  is  long,  as  already  stated.  The  lesion  is  uncommon.  I  have 
seen  three  cases  all  on  the  genitals.  Two  of  them  were  sent  for  inspec- 
tion from  the  Bellevue  Dispensary,  by  Dr.  E.  A.  Banks,  of  New  York. 
The  largest  was  nearly  a  half-inch  in  diameter  at  the  base,  and  elevated 
quite  a  third  of  an  inch  above  the  surface  of  the  integument. 

Subjective  symptoms  of  chancroids. — There  are  none  in  a  typi- 
cal case.  An  uninflamed,  uncomplicated  chancroid  is  not  painful.  It 
itches  or  prickles  somewhat  at  times,  but  nothing  more.  If,  however, 
from  its  position  it  is  subjected  to  irritation  (anus,  end  of  penis),  or  from 
local  applications  or  other  cause  it  becomes  at  all  inflamed,  then  it  be- 
comes painful,  more  or  less  so  according  to  the  individual  and  the 
amount  of  inflammation.  Practically,  chancroid  rarely  exists  clinically 
free  from  irritation,  and  it  is  generally,  therefore,  found  to  be  painful, 
sometimes  acutely  so.  A  rapidly  spreading  chancroid  is  painful,  as  is 
also  a  chancroid  when  attacked  by  gangrene  or  phagedsena. 

Condition  of  the  base. — The  base  of  an  unirritated  chancroid  is  soft. 
If  inflamed  from  irritation,  it  becomes  hard,  indurated,  and  feels  as  a  small 
boil  in  the  skin  sometimes  does.  This  induration  sometimes  cannot  be 
distinguished  with  certainty  from  the  induration  of  syphilitic  chancre. 
Generally,  however,  the  difference  is  striking.  The  induration  of  chancroid 
is  manifestly  an  inflammatory  affair.  The  integument  is  discolored  for  a 
certain  distance  around  the  edge  of  the  ulcer,  with  a  distinct  inflamma- 
tory blush.  The  tissues  give  to  the  fingers  the  sensation  of  being  matted 
together,  glued  to  each  other  and  to  the  surrounding  parts.  The  edge 
of  the  induration  is  not  sharply  defined,  but  fades  away  insensibly  into 
the  surrounding  tissues.  The  hard  mass  is  adherent  to  such  portions  of 
integument  as  override  it,  and  often  closely  attached  to  the  parts  be- 
neath. Pressure  upon  the  induration  causes  pain. 

How  different  is  all  this  from  the  typical  induration  of  a  syphilitic 
chancre — that  tense,  elastic,  insensitive,  non-adherent,  sharply  defined  un- 
derlying induration  so  familiar  to  the  fingers  once  accustomed  to  it,  and 
yet  so  difficult  to  be  certain  about  in  all  cases  in  which  it  is  imperfectly 


CHANCROID.  23 

developed.  The  induration  of  syphilitic  chancre  often  precedes  the  ulcer, 
or  occurs  simultaneously  with  it.  That  of  chancroid  always  follows  the 
ulcer. 

Duration  of  chancroid. — A  typical  ordinary  chancroid  untreated  lasts 
in  most  individuals  from  four  to  eight  weeks,  according  to  its  size.  If 
very  small,  it  gets  well  perhaps  sooner.  The  larger  it  gets  the  longer 
time  does  it  require  for  cicatrization.  Abortive  pustules  and  imperfect 
"  takes  "  get  well  in  a  few  days.  Toward  the  end  of  a  series  of  auto- 
inoculations  in  syphilization,  when  the  virulent  quality  of  the  pus  is  dy- 
ing out,  the  ulcers  grow  smaller  and  get  well  sooner. 

Variations  in  duration. — Irritated  and  inflamed  chancroids  are  slow 
in  getting  well.  To  this  class  belong  all  chancroids  about  natural  orifices 
or  where  motion  is  apt  to  disturb  them,  such  as  chancroids  of  the  anus, 
of  the  meatus  urinarius,  of  the  orifice  of  the  prepuce,  upon  the  back  of  a 
knuckle.  Extensive  chancroids  of  the  vagina  and  rectum  in  the  female, 
and  of  the  rectum  in  the  male,  sometimes  last  indefinitely.  They  cease  in 
the  end  to  be  true  chancroids,  and  their  pus  ceases  to  be  auto-  or  hetero- 
inoculable.  Their  bases  become  indurated,  they  remain  in  part  cicatrized 
(chancroidal  structure  of  the  rectum),  in  part  ulcerated,  and  frequently 
pass  for  tertiary  syphilitic  ulcerations.  Bois  de  Loury  and  Costilhes ! 
have  described  some  forms  of  these  ulcers.  Differential  diagnosis  between 
them  and  syphilitic  similar  lesions  and  some  forms  of  epithelial  cancer  is 
sometimes  very  difficult.  Internal  treatment  does  not  affect  them.  Lo- 
cal stimulating  treatment  sometimes  cures  them.  Bridge,  of  New  York, 
cured  a  bad  case  in  the  rectum,  on  one  occasion,  by  lumbar-colotomy.  In 
the  vagina  excision  is  the  best  treatment.  These  ulcers  are  rarely  en- 
countered except  in  the  wards  of  a  large  hospital.  Charity  Hospital  of 
this  city  always  has  a  number  of  them  in  its  wards.  They  are  customarily 
found  upon  the  persons  of  old  prostitutes. 

The  duration  of  chancroid  is  greatly  influenced  by  phagedaena.  Four- 
nier  has  reported  a  case  lasting  fourteen  years. 

An  uncomplicated  chancroid  occasionally  relapses,  often  without  ob- 
vious cause.  This  is  by  no  means  common,  but  it  has  been  noted,  and  it 
is  possible  for  a  chancroid  which  has  almost  cicatrized  to  break  down  again 
into  ulceration  and  spread  possibly  to  the  same  extent  as  before,  or  even 
farther. 

Cicatrix  of  chancroid. — An  ordinary  uncomplicated  chancroid  may 
fail  to  destroy  the  papillary  layer  of  the  integument,  and  in  such  case  no 
scar  is  left.  Generally  the  scar  is  quite  visible,  especially  when  occurring 
upon  the  outer  integument,  and,  of  course,  once  formed  it  is  permanent. 
It  is  generally  thin  and  smooth,  never  pigmented. 

1  Des  ulcerations  chroniques,  ou  chancres  chroniques  des  parties  genitales  de  la 
femme.  Paris,  1845. 


CHAPTER  III. 
CHANCROID. 

DIAGNOSIS,    PROGNOSIS,    AND    TREATMENT. 

Diagnosis. — Diagnostic  Table  of  Chancre,  Chancroid,  and  Herpes. — Ulcerated  Non-viru- 
lent Abrasions. — Different  Varieties  of  Pseudo-chancre  and  their  Treatment. — Six 
Propositions  of  Importance  bearing  upon  the  Question  of  Auto-inoculation  for  Pur- 
poses of  Diagnosis. — The  Prognosis  of  Chancroid.— The  Treatment  of  Chancroid. 
— Prophylactic  Treatment. — Radical  Treatment. — The  Reason  why  Cauterization 
will  not  always  arrest  a  Chancroid.—  How  to  cauterize  a  Chancroid. — Palliative 
Treatment  of  Chancroid. — lodoform  and  its  Use,  and  other  Topical  Applications. 
— Anal  and  Rectal  Chancroids. — Urethral  Chancroids. — Sub-preputial  Chancroids. 
— Chancroid  at  the  Margin  of  the  Prepuce. — Chancroid  of  the  Vulva  and  Vagina. 
— Chancroid  of  the  Fingers. 

FOR  clinical  purposes  the  differential  diagnosis  of  chancroid  is  with 
syphilitic  chancre,  and  with  that  alone.  The  doubt  may  arise  as  to  whether 
a  given  lesion  be  a  chancroid,  or  a  solitary  herpetic  ulcer,  or  an  ulcerated 
abrasion;  and,  although  scientifically  these  points  are  interesting  and  im- 
portant, they  are  not  paramount. 

It  is  only  possible  to  make  a  differential  diagnosis  clear  within  short 
limits  of  space  by  arranging  the  typical  features  of  the  lesions  under  com- 
parison in  the  form  of  a  table. 

Although  syphilitic  chancre  is  to  be  described  later  on,  yet  it  is  expe- 
dient to  place  a  short  diagnostic  table  here,  on  account  of  the  context. 
This  table  only  deals  with  the  important  broad  typical  characters  of  the 
two  sores.  For  closer  details  of  the  minor  features  of  syphilitic  chancre 
in  differential  diagnosis,  the  reader  is  referred  to  the  more  extensive  table 
later  on. 

A  diagnostic  table,  to  be  accurate,  must  be  minute  in  detail;  but  this 
minuteness  destroys  its  value  for  clinical  purposes  to  the  student,  who 
wants  the  broadest  possible  distinctions,  clearly  made  and  strongly  con- 
trasted. It  is  therefore  expedient  to  give  two  diagnostic  tables,  the  first 
broad,  clear,  short,  referring  to  the  typical  ulcer,  and  not  considering  ex- 
ceptions or  complications;  the  second,  more  in  detail,  for  fear  that  the  first 
might  lead  into  error.  But  few  points,  and  those  cardinal,  will  be  made 
in  the  first  table,  that  it  may  be  a  sort  of  primer  of  diagnosis  for  virulent 
venereal  disease.  It  seems  best  to  include  herpes  in  the  first  table.  The 
second  table  will  be  given  after  a  description  of  syphilitic  chancre. 

A  diagnostic  table  cannot  cover  all  the  ground,  and  it  is  not  intended 
to  do  so.  It  is  in  the  main  accurate  for  typical  cases  only,  and  its  func- 
tion is  to  serve  somewhat  as  does  a  diagrammatic  chart.  A  table  of  this 
sort  is  sometimes  of  very  great  value,  but  it  cannot  be  depended  upon  io 
exceptional  cases. 


CHANCROID. 


25 


Diagnostic  Table  of  the  Distinctive  Features  upon  the  Genitals  of  Pure 

Typical  Cases  of 


SYPHILITIC  CHANCRE. 


CHANCROID. 


HERPES   PROGENITALIS. 


1.  History. — Sexual  con- 
tact with  a  syphilitic  chan- 
cre or  mucous  patch,  the  pa- 
tient himself  being  virgin  of 
syphilis. 

2.  Situation. — Anywhere. 

3.  Incubation. —  About 
three  weeks. 

4.  Origin. — Papule. 

5.  Type. — Bloody  excori- 
ation. 

6.  Number. — Unique. 

7.  Physiognomy. — Round, 
raw  papule,  or  livid  excoria- 
tion, or  funnel-shaped  ulcer. 
If  an  ulcer,  the  edyes  are 
adherent,  the  floor  is  pulta- 
ceous,   the   suppuration    is 
scanty. 

8.  Auto-inoculation  fails. 

9.  Course. — Slow  through- 
out. 

10.  Pain. — Absent. 

11.  Induration. — Present. 


Sexual  contact  with  a 
chancroid ;  syphilis  has  noth- 
ing  to  do  with  either  party. 


Most  common  in  the  fossa 
alongside  of  the  frenum. 
About  three  days. 


Pustule. 

Suppurating  deep  ulcer. 

Multiple. 

Round  ulcer,  with  sharply 
cut,  abrupt  edges,  often  un- 
dermined, uneven  pultace- 
ous  floor,  suppurating  abun- 
dantly. 

Succeeds. 

Rapid,  but  gets  well  slow- 
ly. 
Present. 

Absent. 


Of  ten  spontaneous;  some- 
times follows  unaccustomed 
sexual  intercourse.  Syphilis 
may  be  ignored  in  searching 
for  a  cause. 

Usually  subpreputial. 

If  due  to  intercourse, 
twenty-four  hours  to  a  few 
days. 

Several  clusters  o£  vesi- 
cles. * 

Irregular,  superficial  ul- 
cer. 

Multiple. 

Superficial  ulcer,  with 
thin  borders  plainly  (at  first) 
composed  of  a  number  of 
small  ulcers  which  have  run 
together. 


Fails. 

Rapid,  and  gets  well 
promptly. 

Sharp,  tingling  sensation 
at  first. 

Absent. 


These  features  are  very  clearly  different  in  the  different  lesions.  It 
takes  more  than  one  symptom  to  make  a  disease,  and  very  few  symptoms 
are  absolutely  constant  in  any  disease.  A  typical  chancroid  ought  to  ac- 
cord very  closely  to  the  description  given  above.  When  it  is  much  com- 
plicated it  may  be  quite  wide  of  the  mark.  In  such  case  its  peculiarities 
may  be  found  detailed  in  the  more  thorough  diagnostic  table,  following 
the  description  of  syphilitic  chancre,  at  p.  97.  In  all  cases  of  doubt,  in 
every  instance  where  the  few  broad  distinctions  clearly  pointed  out  in 
this  table  fail  to  make  the  diagnosis  certain,  there  is  no  safety  in  any 
course  but  delay.  Delay  will  always  make  the  diagnosis  more  certainly 
than  any  table.  One  mistake  in  the  wrong  direction,  one  condemnation 
of  a  healthy  person  to  the  years  of  distress  of  mind  which  he  is  sure  to 
suffer  if  he  supposes  himself  to  be  syphilitic — and  all  the  more  in  some 
cases  if  no  symptoms  of  the  disease  appear  later  to  confirm  his  doubts — 
one  such  error  more  than  counterbalances  any  possible  good  that  might 
arrive  in  any  number  of  cases  by  a  few  weeks'  gain  in  the  time  of  diag- 
nosis between  chancroid  and  syphilis. 

Besides  syphilitic  chancre,  there  are  other  lesions  liable  to  be  mistaken 
for  chancroid,  but  none  of  them  commonly  give  any  trouble  to  the  close 
observer. 

An  abrasion  acquired  during  sexual  intercourse,  and  ulcerating  subse- 
quently, is  sometimes  suggestive  of  chancroid.  Such  an  abrasion  occurs 


26  THE   VENEREAL   DISEASES. 

at  the  moment  of  contact,  and,  unless  small,  is  usually  shortly  afterward 
recognized — perhaps  by  a  drop  of  blood. 

The  edges  of  such  an  abrasion  are  generally  jagged,  and  the  base  of 
the  ulcer  but  little  depressed,  and  discharging  a  thin  sero-pus.  But  yet 
such  an  abrasion  by  neglect  in  debilitated  persons,  by  lack  of  cleanliness, 
by  inappropriate  treatment  (partial  cauterizations  with  nitrate  of  silver), 
may  acquire  in  time  a  physiognomy  so  nearly  resembling  that  of  chancroid 
that  a  diagnosis  is  almost  impossible.  Under  these  circumstances  there 
remain  the  alternatives  of  auto-inoculation  over  the  insertion  of  the  del- 
toid, under  the  nipple  or  on  the  outer  and  upper  part  of  the  thigh;  of 
delay,  with  the  use  of  cleanliness,  soothing  and  mildly  stimulating  local 
dressings,  and  tonics  internally;  or,  finally,  if  the  patient's  state  of  mind 
calls  for  it,  and  the  person  from  whom  he  acquired  his  sore  cannot  be 
found  for  inspection,  no  harm  can  come  by  adopting  the  conclusion  that 
the  suspicious  ulcer  may  be  a  source  of  poison  to  others,  and  treating  it 
as  if  it  were  a  chancroid,  by  thorough  destructive  cauterization. 

Should  a  patient  present  himself  on  the  morning  after  suspicious  in- 
tercourse with  an  abrasion  still  fresh  upon  him,  what  is  to  be  done  ?  It 
is  manifestly  an  abrasion,  and  the  patient  has  been  exposed  to  any  poison 
that  may  have  been  present  in  his  partner.  Several  hours  have  passed, 
absorption  has  been  accomplished;  what  is  to  be  done  ?  Very  little  ex- 
cept to  make  a  reserved  prognosis.  Hill's  case,  Diday's  experience,  the 
results  of  the  excisions  of  syphilitic  chancres  by  Auspitz  and  Kolliker  (p. 
93),  make  it  improper  to  promise  any  immunity  from  infection  if  true 
syphilis  be  dreaded;  and  if  chancroid  be  feared,  it  is  not  of  enough  impor- 
tance to  justify  a  painful  cauterization  until  the  lesion  has  developed. 
Cleanliness,  a  little  lead-water  and  a  few  days'  time  is  all  that  a  recent 
abrasion  calls  for.  The  same  treatment  also  applies  to  herpes,  but  it  is  of 
advantage  to  make  the  lotion  somewhat  more  stimulating  than  lead-water 
for  herpetic  cases.  Thus,  a  simple  treatment  for  a  week  or  ten  days  be- 
comes an  important  aid  to  diagnosis,  capable  of  saving  the  patient  subse- 
quent distress  and  shielding  the  physician  from  blame. 

The  diagnosis  between  chancroid  and  an  ulcerated  syphilitic  lesion 
situated  under  the  prepuce  sometimes  gives  trouble.  An  ulcerated  mucous 
patch  rarely  exists  unaccompanied  by  other  lesions,  through  aid  of  which 
its  nature  may  be  defined.  The  pseudo-chancre,  however,  gives  trouble. 
It  is  rare  as  a  lesion  clinically,  and  different  ulcers  have  been  described 
as  pseudo-chancres  by  different  observers.  Founder's  pseudo-chancre  of 
syphilitics — a  secondary  induration  with  ulceration  often  occurring  at  the 
seat  of  the  primary  lesion — is  not  likely  to  give  any  diagnostic  trouble. 

A  spontaneous  pustule  may  occur  under  the  prepuce  of  a  syphilitic 
patient  without  any  suspicious  contact,  and  ulcerating  may  resemble 
chancroid  closely.  This  is  a  pseudo-chancre.  An  ulcerated  gumma  is 
quite  apt  to  appear  under  the  corona  glandis,  near  the  pocket  of  the  fre- 
num,  late  in  syphilis.  This  ulcer  resembles  a  chancroid,  and  is  quite  likely 
to  eat  into  the  urethra  if  not  arrested  by  treatment.  I  have  seen  several 
instances  of  both  of  these  sores,  particularly  the  latter,  mistaken  for  chan- 
croid. The  first  resembles  chancroid  greatly;  the  latter  not  so  closely, 
because  its  underlying  base  and  border  are  quite  hard,  and  its  history 
shows  that  it  started  as  an  induration  under  the  mucous  membrane. 

Finally,  a  pseudo-chancre  may  occur  after  suspicious  intercourse,  due 
to  contagion  with  any  pus,  such  as  pus  from  an  irritated  syphilitic  chan- 
cre, an  ulcerated  mucous  patch,  from  vaginal  discharges;  and  any  of  these 
kinds  of  pus  may  produce  (as  is  well  known),  upon  the  body  of  a  patient 


CHANCROID.  27 

already  syphilitic,  a  suppurating  sore  much  resembling,  perhaps  exactly 
like,  a  chancroid — but  not  a  chancroid,  as  has  been  shown  in  Chapter  II. 
Such  a  lesion  is  a  pseudo-chancre. 

Only  two  other  lesions,  so  far  as  I  am  aware,  have  ever  been  called 
pseudo-chancre.  These  are  the  mixed  chancre  of  Rollet  (to  be  described 
later),  and  the  result  of  inoculation  of  a  true  chancroid  upon  a  syphilitic 
(Tarnowsky),  from  which  latter  a  simple  chancroid  may  be  acquired  by 
another  through  contagion,  or,  if  the  blood  of  the  patient  be  admixed 
with  the  secretion  inoculated,  true  syphilitic  chancre  as  well.  The  name 
of  pseudo-chancre  ought  not  to  be  applied  to  these  two  lesions,  since  it 
leads  to  confusion,  for  the  first  is  a  compound  ulcer  possessed  of  both 
poisons,  the  last  a  simple  chancroid  upon  a  syphilitic  patient. 

The  other  three  pseudo-chancres,  however — (1)  the  spontaneous,  not 
specific,  non-indurated,  sub-preputial  ulcer  of  syphilitics,  (2)  the  result  of 
hetero-inoculation  upon  syphilitics  in  intercourse  with  syphilitic  or  indif- 
ferent pus,  and  (3)  the  ulcerated  perforating  gumma  of  the  genitals — all 
of  these  pseudo-chancres  are  fertile  sources  of  error  in  their  diagnosis 
with  chancroid. 

They  all  occur  upon  patients  already  syphilitic;  the  pus  of  the  first 
two  may  be  auto-inoculable  in  generations — in  each  of  them,  especially 
the  first  and  the  last,  there  may  be  no  other  sign  of  syphilis  present  upon 
the  individual.  Often  a  diagnosis  can  only  be  made  by  a  close  study  of 
the  history  of  the  patient,  and  prolonged  attentive  inspection  of  the  le- 
sion. The  first  two  sometimes  have  the  appearances  of  both  chancre  and 
chancroid,  but  the  resemblance  to  chancroid  is  the  more  striking.  The 
perforating  gumma  is  often  mistaken  for  chancroid,  occasionally  for  lupus. 
A  pseudo-chancre  rarely  looks  like  a  true  syphilitic  chancre  (Fournier's 
pseudo-chancre  of  course  excepted),  but  it  has  certainly  been  sometimes 
described  as  such,  and  the  patient,  on  its  account,  has  been  credited  with 
two  attacks  of  true  syphilitics  (p.  83.) 

Hence,  the  practitioner  may  find  himself  in  face  of  a  pseudo-chancre, 
one  of  the  three  mentioned,  and  be  unable  to  say  whether  it  is  a  chan- 
croid, or  not.  In  such  a  case  what  is  he  to  do  ?  Perhaps  the  safest  rule 
is  this:  cauterize  thoroughly  any  pseudo-chancre  which  is  auto-inoculable, 
and  in  case  of  any  reasonable  suspicion  that  the  ulcer  is  a  gumma,  give 
iodide  of  potassium.  The  patient  already  has  syphilis,  and  he  is  in  no  dan- 
ger of  harm  from  a  little  more  anti-syphilitic  treatment.  The  first  two  of 
the  three  ulcers  under  consideration  will  get  well  by  local  treatment  alone, 
or  by  no  treatment.  They  rarely,  if  ever,  become  phagedenic.  The  last 
ulcer,  the  perforating  gumma,  is  another  matter.  This  ulcer  also  gets 
well  in  the  long  run,  spontaneously,  but  meantime  it  has  destroyed  tissue, 
perhaps  eaten  into  the  urethra,  or  made  a  ragged  excavation  in  the  head 
of  the  penis.  Sympathetic  suppurating  bubo  is  rarely,  if  ever,  found 
with  pseudo-chancre,  and  least  of  all  with  this  ulcerated  gumma.  The 
main  hope  of  diagnosis  is  in  studying  the  history  of  the  sore  and  being 
familiar  with  its  course  and  appearance.  I  have  published  elsewhere  the 
record  of  a  case  *  in  which  a  tertiary  destructive  ulcer  of  the  frenum  had 
been  cauterized  by  a  gentleman  in  high  authority,  as  chancroid,  and 
where  the  malady,  failing  to  get  well,  had  finally  been  pronounced  lupus, 
and  extirpation  with  the  knife  gravely  decided  upon.  The  man  recovered 
promptly  under  anti-syphilitic  treatment. 

Cauterization  does  not  cure  these  cases,  although  they  may  improve 

1  Case  XLVIII. :   Van  Buren  and  Keyea.     Op.  cit.,  1st  ed.,  p.  537. 


28  THE    VENEREAL   DISEASES. 

temporarily  under  the  burning.  More  tissue  is  destroyed  by  the  local 
treatment  than  can  be  spared,  and  valuable  time  lost  which  might  have 
been  employed  in  intelligent  general  treatment. 

In  only  one  form  of  the  pseudo-chancre,  then,  can  a  mistake  in  diag- 
nosis lead  to  any  serious  misfortune,  namely,  in  the  perforating  gummy 
ulcer  of  the  penis.  A  knowledge  of  this  fact  is  the  best  safeguard 
against  committing  a  serious  error.  The  lesion,  ulcerated  gumma  of  the 
penis,  is  described  in  full  on  p.  164. 

Certain  chancroids  are  hidden  from  view.  The  urethral  chancroid 
almost  invariably  involves  the  meatus,  but  possibly  might  be  out  of  sight. 
A  sub-preputial  chancroid  in  case  of  phymosis,  an  anal  chancroid  resem- 
bling fissure — these  and  possibly  other  varieties  cannot  be  diagnosticated 
in  the  usual  way.  In  such  case,  when  the  suspicion  of  chancroid  arises, 
the  test  of  auto-inoculation  is  invaluable.  If  auto-inoculation  produces 
a  characteristic  chancroid  (especially  if  the  patient  be  not  syphilitic  or 
cachectic)  it  may  be  positively  predicated  that  the  source  of  the  inoculated 
pus  was  chancroid. 

In  auto-inoculation  practised  for  purposes  of  diagnosis,  six  facts  should 
be  remembered : 

(1).  A  gangrenous  phagedenic  chancroid  loses  its  poisonous  quality, 
just  as  decomposed  chancroidal  pus  is  no  longer  virulent,  and  auto-inocu- 
lation fails. 

(2).  Auto-inoculation  of  almost  any  pus,  upon  a  patient  already  syphi- 
litic, may  take  and  produce  an  ulcer  resembling  chancroid. 

It  must  be  remembered  that  the  source  of  such  pus  is  not  necessarily 
a  chancroid. 

(3).  An  ulcer  may  be  a  mixed  chancre,  in  which  case  its  auto-inocula- 
tion will  take  as  a  true  chancroid;  but  the  patient  has  syphilis  none  the 
less. 

(4).  Auto-inoculation  of  an  irritated  true  syphilitic  chancre  may  some- 
times take  as  an  ulcer  resembling  chancroid,  and  non-irritated  true  syph- 
ilitic chancre  by  auto-inoculation  very  exceptionally  takes  as  a  papule. 

(5).  A  serpiginous  phagedenic  ulcer  is  auto-inoculable,  but  its  auto- 
inoculation  may  produce  a  chancroid,  which,  in  its  turn,  becomes  phage- 
denic, since  phagedaena  is  a  property  of  the  patient  and  not  of  the  chan- 
croidal virus  he  secretes.  Hetero-inoculation  of  a  phagedenic  chancroid 
is  no  more  apt  to  produce  a  phagedenic  sore  than  is  the  hetero-inocula- 
tion  of  any  other  chancroidal  pus.  The  deduction  is,  if  auto-inoculation 
of  a  phagedenic  sore  be  attempted,  the  site  chosen  for  the  puncture  should 
be  the  breast  under  the  nipple,  since  phagedaena  rarely  occurs  here,  and 
the  ulcer  should  be  at  once  destroyed  as  soon  as  it  can  be  pronounced  a 
take. 

(6).  In  all  cases  of  auto-inoculation  destroy  the  little  ulcer  produced  at 
the  test-point  as  soon  as  it  has  served  its  purpose. 


PROGNOSIS    OF    CHANCROID. 

Uncomplicated  chancroid  gets  well  in  a  few  weeks,  and  never  leads  to 
a  result  more  serious  than  a  triQing  local  scar.  Chancroid  of  the  most 
malignant  type,  attended  by  the  most  serious  complications,  never  produces 
syphilis. 

This  one  fact,  that  chancroid  is  not  a  blood  disease  and  never  produces 
syphilis,  reduces  all  the  damage  it  can  do  its  bearer  to  such  mischief  as 


CHANCROID.  29 

any  ulcer  of  similar  extent  and  severity  might  equally  well  accomplish. 
In  rare  instances  this  damage  is  considerable.  A  severe  and  protracted 
chancroid  of  the  rectum  leads  to  stricture  of  that  gut  with  all  its  distress- 
ing results;  the  mouth  of  the  urethra  may  be  nearly  sealed  up  by  the  con- 
tracting cicatrix  of  a  chancroid. 

The  minor  possible  results  of  deformity  by  eating  into  the  urethra, 
and  of  phymosis  by  cicatricial  contraction,  must  be  remembered. 

Erysipelas  may  attack  a  simple  chancroid  as  well  as  any  other  lesion. 
The  more  extensive  and  complicated  sores  naturally  lead  to  serious  local 
consequences. 

Phagedaena  may  stretch  itself  over  large  portions  of  the  surface  of  the 
body,  and  last  for  years. 

Sloughing  phagedoena  may  destroy  great  segments  of  the  penis,  or  so 
eat  away  its  outer  investment,  that  the  resulting  scar  leaves  the  organ 
practically  useless.  A  slough  has  been  known  to  open  a  large  vessel,  and 
serious  haemorrhage  as  a  complication  thus  becomes  possible. 

These  extreme  results  are  indeed  possible,  but  they  are  so  rare  that 
they  may  be  disregarded  in  giving  an  ordinary  prognosis. 


TREATMENT   OF    CHANCROID. 

Preventive  treatment. — A  number  of  substances  have  been  used 
experimentally  to  abort  chancroids  produced  by  auto-inoculation.  Of 
late  years  but  little  has  been  done  in  this  direction,  and  the  text-book  on 
syphilis  written  by  Rollet '  contains  about  all  that  is  known  on  the  subject. 
Preventive  treatment  is  rarely,  if  ever,  called  for  by  the  patient.  In  fact, 
the  incubation  period  is  so  short  that  a  patient  has  already  a  typical  mi- 
nute chancroid  when  he  first  discovers  it,  and  when  he  seeks  his  physician 
the  chancroid  is  perfectly  formed  and  beyond  the  reach  of  prophylactic 
measures.  The  only  preventive  treatment  to  be  recommended  to  a  pa- 
tient is  that  he  avoid  all  sources  of  contagion;  and  the  best  preventive 
treatment  of  the  spread  of  ulcers  upon  a  patient  by  spontaneous  auto-inoc- 
ulation, is  destruction  of  the  poison  at  the  source  of  contagion  on  his  own 
person,  by  caustic,  or  the  most  absolute  cleanliness,  if  total  destruction 
be  impossible.  The  abortive  treatment  can  only  be  called  for  when  the 
surgeon  has  contaminated  a  fissure  on  one  of  his  own  fingers  in  manipu- 
lating a  patient  with  a  poisonous  discharge.  Rollet  states  that  all  the 
strong  mineral  acids,  some  of  the  vegetable  acids,  the  alkaline  caustics, 
and  certain  salts,  such  as  chromate  of  potash,  sulphate  of  iron,  diluted 
with  water  until  they  are  too  weak  to  attack  the  healthy  epidermis,  will 
cause  a  point  of  artificial  inoculation  to  abort,  if  kept  in  contact  with  the 
surface  for  several  hours  and  applied  within  a  short  period  of  the  inocula- 
tion— three  to  six  hours,  occasionally  as  late  as  twelve  to  twenty-four 
hours.  Rollet  and  Rodet  think  best  of  a  concentrated  solution  of  citric 
acid. 

These  means  are  very  simple  and  easy  of  application.  It  is  difficult  to 
believe  that  absorption  is  so  slow  that  anything  could  avail  twenty-four 
or  even  six  hours  after  inoculation.  If  this  be  true,  it  constitutes  a  dif- 
ference between  chancroid  and  syphilis  greater  than  any  yet  advanced; 
for  the  rapidity  of  absorption  of  the  virus  of  the  latter,  and  inability  of 
local  treatment  to  abort  it  after  it  has  once  been  applied,  are  well  known. 

1  TraitS  des  maladies  veneriennes. 


30  THE   VENEREAL   DISEASES. 

Rollet's  suggestions,  then,  may  be  tried  ;  but  practically,  the  surgeon 
can  do  better.  If  he  fears  inoculation  at  a  fissure  in  his  finger,  he  immedi- 
ately plunges  his  finger  into  any  water  at  hand  (preferably  containing 
carbolic  acid),  rinses  it  rapidly,  dries  it  promptly  upon  a  clean  towel,  and 
immediately  places  the  suspected  spot  in  his  mouth  and  sucks  it.  The. 
unabraded  epithelium  of  the  mouth  is  a  bar  to  contagion  should  any  virus 
survive  the  washing,  and  the  comparative  immunity  of  the  face  to  chan- 
croid is  another  safeguard  from  double  contagion.  After  sucking  for  a 
moment  and  expectorating  the  saliva,  the  fissure  should  be  touched  with  a 
ten  per  cent,  solution  of  carbolic  acid,  which  is  slightly  caustic,  a  strong 
solution  of  nitrate  of  silver,  or  even  with  chromic  acid,  and,  if  the  precau- 
tions have  been  followed  carefully,  contagion  will  not  occur  at  the  acci- 
dentally inoculated  point. 

Radical  treatment. — Chancroid  owes  its  prolonged  existence  to  the 
virulence  of  its  pus.  Destroy  that  virulence  and  the  poisonous  quality 
at  once  disappears,  the  ulcer  becomes  a  simple  traumatism,  and  the  pro- 
cess of  repair  begins.  Nature  herself  demonstrates  this  method  of  cure. 
Sometimes  a  chancroid  inflames — a  sub-preputial  chancroid,  for  example. 
The  tissues  become  tumid  and  congested  around  it,  its  circulation  becomes 
strangulated,  its  surface  sloughs.  As  soon  as  the  slough  has  formed  the 
pus  ceases  to  be  auto-inoculable  (if  the  subject  be  reasonably  healthy),  and 
repair  goes  on  at  once  with  the  throwing  off  of  the  dead  tissues.  Any 
means,  therefore,  which  will  kill  all  the  living  tissues  constituting  the  base 
of  the  ulcer  and  at  the  same  time  neutralize  all  the  free  poison  upon  the 
surface,  will  radically  cure  a  chancroid. 

There  are  but  two  exceptions  to  this  rule:  (1).  Unless  a  chancroid 
is  very  young,  it  is  apt  to  return  if  cut  out  or  cauterized.  I  have  cut  away 
a  chancroid  with  half  an  inch  of  prepuce  lying  between  it  and  the  healthy 
parts,  and  yet  that  portion  of  the  wound  where  the  lymphatics  were  most 
abundant — the  neighborhood  of  the  frenum — became  chancroidal.  The 
most  scrupulous  attention  to  cleanliness  was  paid  in  this  operation.  (2). 
Some  old  chancroids  certainly  do  not  get  well  after  the  most  extensive  cau- 
terization. This  is  notoriously  true  of  serpiginous  phagedenic  sores. 
Each  cauterization  brightens  them  and  they  do  better  for  a  time,  but  the 
chancroidal  features  return  to  the  ulcer  and  repair  fails  to  follow  the  clear- 
ing away  of  the  slough. 

This  is  never  the  case  with  a  young  chancroid.  Such  an  ulcer,  cau- 
terized thoroughly,  ceases  absolutely  to  exist  as  a  chancroid. 

The  explanation  to  this  is  not,  I  think,  so  difficult  as  it  seems  at  first 
glance.  It  is  the  poison,  which  must  be  destroyed  to  cure  a  chancroid  by 
cauterization.  This  poison  resides  in  the  pus-corpuscle  upon  the  surface 
of  the  sore,  and  is  certainly  also  present  in  the  base  of  the  sore.  In  the 
young  ulcer  it  is  confined  to  these  two  localities,  and  a  cauterization  which 
includes  the  infiltrated  tissues  underlying  the  ulcer  certainly  destroys  the 
virulence  of  the  sore. 

In  an  old  chancroid,  however,  and  especially  in  a  creeping,  phagedenic 
chancroid,  the  poison  has  infiltrated  the  tissues  for  a  certain  distance  be- 
yond the  base  of  the  ulcer,  and  cauterization  does  not  destroy  all  the  poi- 
son. It  is  eliminated  from  these  tissues  in  course  of  nature  by  the  white 
corpuscles,  the  wandering  cells,  which  become  possessed  of  it  and  wash  it 
out  at  the  ulcerated  surface.  If  the  ulcerated  surface  is  destroyed,  it  be- 
comes reinfected  by  poison  brought  from  beneath;  and  for  the  same  rea- 
son the  wound  of  circumcision  frequently  becomes  poisoned,  when  the 
prepuce  is  the  seat  of  chancroid,  in  spite  of  such  precautions  as  burning 


CHANCROID.  31 

the  chancroid  previously  to  the  ablation  of  the  foreskin,  and  perfect  clean- 
liness during  and  after  the  operation, 

Why  it  is  that  the  poison  in  ordinary  cases  dies  out  after  a  few  weeks, 
and  is  all  eliminated  with  the  pus,  while  in  other  cases  of  advancing  pha- 
gedasna  it  seems  able  to  perpetuate  itself  almost  indefinitely,  it  is  impos- 
sible to  say,  since  we  do  not  understand  the  nature  of  the  poison.  The 
probability  is  that  the  difference  is  solely  a  question  of  the  soil  in  which 
the  chancroidal  poison  finds  itself,  for  phagedaena  is  a  quality  of  the  indi- 
vidual, and  does  not  imply  the  inoculation  of  any  special  variety  of  chan- 
croidal pus. 

With  the  understanding,  then,  that  in  many  old  cases  the  chancroidal 
poison  is  widespread,  and  cannot  be  all  reached  by  any  means  capable  of 
totally  destroying  the  ulcer,  it  is  yet  a  uniform  opinion  among  authorities 
that  total  destruction  of  the  ulcer  is  the  only  certain  cure  of  chancroid — 
and  this  is  true  without  exception  in  all  cases  where  the  chancroid  is 
young.  At  exactly  what  age  chancroid  ceases  to  be  curable  by  the  de- 
struction of  its  surface,  and  a  reasonable  amount  of  tissue  beyond,  cannot 
be  stated.  Cauterization  never  does  harm,  and  the  rule  is  to  cauterize  a 
chancroid  thoroughly  as  soon  as  its  diagnosis  is  established,  and  to  destroy 
all  points  of  diagnostic  auto-inoculation  very  promptly.  This  gives  the 
best  chance  of  speedy  and  permanent  cure. 

Potential  caustics  are  most  manageable  as  destructive  agents,  and 
therefore  better  than  other  means  of  destruction.  Any  surgeon  may  use 
his  favorite  caustic,  acid  or  alkaline,  but  it  must  be  a  strong  one.  Acetic 
acid  or  carbolic  acid  will  not  do,  and  nitric  and  sulphuric  acids  fill  all  the 
requirements  of  any  case.  The  chloride  of  zinc  and  other  pastes  pain 
more  than  the  acids,  and  their  application  requires  much  more  skill  and 
care  than  the  latter,  that  they  may  be  applied  thickly  enough  to  destroy 
all  the  tissue  required,  and  not  left  on  so  long  as  to  destroy  too  much. 
The  nitric  and  sulphuric  acids  meet  the  wants  of  all  cases — the  first  to  be 
used  as  a  liquid,  the  second  as  a  paste  (carbo-sulphuric). 

To  prepare  a  chancroid  for  cauterization,  all  pus  should  be  removed 
from  it  by  holding  pellets  of  absorbent  cotton  upon  it,  and  the  surround- 
ing surface  should  be  wiped  as  dry  as  possible.  Upon  the  ulcer  so  pre- 
pared, a  drop  of  pure  carbolic  acid  is  first  placed,  a  little  blotting  or  other 
bibulous  paper  being  ready  in  the  surgeon's  hand  to  absorb  any  excess  of 
acid  that  may  escape  out  of  the  cup  in  the  skin  formed  by  the  chancroid. 
The  carbolic  acid  causes  much  less  pain  than  pure  nitric  acid,  and  it  be- 
numbs the  sensibility  of  the  ulcer  so  that  the  application  of  nitric  acid 
afterward  is  far  less  painful  than  it  would  otherwise  have  been,  and  none 
the  less  effective. 

The  drop  of  carbolic  acid  is  absorbed  out  of  the  chancroid  with  bibu- 
lous paper,  and  the  white,  dry  cup  representing  the  chancroid  is  now 
ready  for  the  final  cauterization. 

A  glass  rod,  drawn  to  a  point,  is  now  dipped  into  fuming  nitric  acid, 
and  enough  acid  placed  upon  the  chancroid  to  fill  its  depression  even 
with  the  surface.  The  bibulous  paper  is  again  used,  if  any  excess  of  acid 
trickles  over.  This  application  is  but  slightly  painful.  The  surrounding 
tissues  are  now  held  tense,  and  the  little  drop  is  watched.  If  the  edges 
of  the  ulcer  are  undermined,  the  point  of  the  glass  rod  should  be  moved 
around  under  the  border  beneath  the  surface  of  the  drop  of  acid,  so  that 
all  the  recesses  of  the  sore  may  be  equally  acted  upon. 

As  the  acid  cauterizes  the  base  of  the  ulcer,  an  areola  of  white  color 
is  seen  to  grow  gradually  around  the  sore  under  the  epithelium.  When 


32  THE    VENEREAL    DISEASES. 

this  areola  gets  to  be  as  broad  as  a  sheet  of  blotting-paper  is  thick,  the 
cauterization  is  perfect.  If  it  does  not  become  so  broad  after  watching  it 
for  two  or  three  minutes,  the  drop  of  acid  should  be  soaked  out  of  the  ulcer 
and  a  new  one  put  in — and  so  on  until  the  areola  of  white  dead  cauterized 
tissue  reaches  the  required  thickness.  Then  the  sore  is  dried  perfectly, 
covered  with  scraped  lint  or  absorbent  cotton,  and  left  to  itself.  It  is 
rarely  necessary  to  alkalinize  the  surface;  but  this  may  be  promptly  done, 
if  thought  necessary,  with  a  drop  of  liquor  potassae. 

The  white  piece  of  tissue  killed  by  the  acid  turns  brown,  then  black. 
If  its  position  is  such  that  it  may  be  exposed  to  the  air,  it  is  best  to  let  it 
dry  up  and  heal  by  scabbing,  as  it  will  sometimes  do.  Most  chancroids, 
however,  are  sub-preputial.  The  little  eschar  begins  shortly  to  slough  off, 
a  line  of  healthy  suppuration  forms  around  and  beneath  it.  Absorbent 
cotton  or  moistened  lint  answer  perfectly  well  as  dressings  to  absorb  the 
pus,  or,  if  stimulation  be  needed,  a  good  dressing,  and  one  perfectly 
cleanly,  is  either  of  the  following: 

$.     Spts.  rect 3  iss. — iij. 

Aquae q.  s.  ad    §  i. 

M. 
Or- 

^ .     Chloral  hydrat gr.  i. — iij. 

Aquae 3  i. 

M. 

In  many  cases  a  little  vaseline  or  balsam  of  Peru,  upon  a  piece  of  pre- 
pared lint,  gives  most  satisfaction. 

A  small  chancroid  thoroughly  burned  ought  to  be  well  in  ten  days, 
more  extensive  sores  require  more  time. 

In  case  it  is  decided  to  cauterize  a  chancroid  with  an  irregular  base, 
overhanging  edges,  or  pockets,  where  perhaps  from  the  position  of  the 
sore  the  liquid  acid  cannot  be  evenly  applied  to  the  whole  surface,  the 
carbo-sulphuric  paste  meets  the  requirements  of  the  case.  This  paste 
originated  with  Ricord,  and  is  formed  by  mixing  vegetable-charcoal  dust 
with  pure  sulphuric  acid  until  a  black  paste  is  formed.  This  is  kept  tightly 
corked  in  a  bottle.  It  is  applied  with  a  flat  piece  of  wood  and  pressed 
down  into  all  the  inequalities  of  the  sore.  The  ulcer  is  filled  up  even 
with  the  surface,  and  the  paste  bound  on  and  left  to  do  its  work  of  de- 
struction. There  is  no  danger  that  it  will  eat  too  deeply  into  the  tissues. 
It  chars  the  tissues  before  it,  and  the  cauterizing  action  cannot  penetrate 
beyond  a  safe  depth. 

But  two  cautions  are  to  be  given  relative  to  the  cauterization  of  un- 
complicated chancroid  in  the  usual  positions. 

(1).  Never  touch  a  chancroid  with  caustic  unless  each  and  every 
abrasion  in  the  neighborhood,  and  all  suppurating  spots,  can  be  totally  and 
simultaneously  destroyed.  For  if  any  chancroidal  pus  remains  unneu- 
tralized  it  is  ready  to  poison  the  healthy  ulcer  left  by  the  separation  of 
the  slough,  and  to  reconvert  it  into  a  chancroid.  Thus,  chancroid  at  the 
margin  of  the  prepuce  cannot  be  cauterized  if  sub-preputial  chancroid 
also  exists  and  is  spared. 

(2).  In  case  of  numerous  sub-preputial  chancroids,  if  the  foreskin  be 
naturally  tight  the  reaction  following  cauterization  may  inflame  the  pre- 
puce sufficiently  to  cause  phymosis  and  conceal  the  cauterized  spots  from 
view.  A  fear  of  this  occurrence  need  not  deter  the  surg-eon  from  a  free 


CHANCROID. 


use  of  the  cautery.  The  cavity  of  the  prepuce  can  be  kept  syringed  out, 
and  if  the  cauterization  has  been  effective  the  chancroids  will  certainly 
get  well,  even  within  an  inflamed  prepuce. 


PALLIATIVE    TREATMENT    OF    CHANCROID. 

When  all  the  chancroids  cannot  be  reached,  when  the  surfaces  in- 
volved are  quite  extensive,  the  chancroids  already  a  number  of  weeks  old 
and  not  phagedenic,  and  in  cases  of  certain  regional  chancroids,  urethral, 
anal,  rectal,  at  the  margin  of,  or  beneath  a  tight  prepuce,  cauterization 
is  not  generally  applicable,  and  palliative  treatment  must  be  employed. 

When  all  the  chancroids  cannot  be  reached,  or  are  so  large  and  old 
that  cauterization  is  not  justifiable,  cleanliness  is  the  first  requisite  of 
treatment.  Frequent  washings  with  warm  water  lightly  carbolized  (half 
of  one  per  cent.),  are  to  be  recommended.  The  surfaces  should  be 
washed  with  a  syringe,  or  by  trickling  warm  water  upon  them,  and  dried 
by  touching  them  with  bibulous  paper.  Unquestionably  the  most  effi- 
cient local  application  for  these  chancroids  is  iodoform,  and  its  applica- 
tion pure,  in  powder  or  mixed  into  a  paste  with  glycerine  and  scented 
with  essential  oils,  is  rarely  painful.  But  respectable  people  will  not  use 
iodoform.  Its  peculiarly  penetrating  and  tenacious  odor  is  unmistak- 
able. Those  who  have  once  smelled  it  upon  any  one  else  fear  disclosure 
from  the  very  fact  of  using  it,  and  most  of  those  who  are  unfamiliar  with 
it  at  first,  soon  get  to  abhor  it.  In  spite  of  all  this  it  remains  the  most 
efficient  local  application  for  chancroids  too  old  to  burn,  and  by  a  careful 
person  can  be  often  so  used  as  to  escape  all  the  disadvantage  attaching 
to  it. 

Nothing  will  disguise  the  odor  of  iodoform.  Oil  of  peppermint  is  per- 
haps the  best  of  the  aromatic  oils  for  the  purpose.  Many  other  sweet- 
smelling  oils  have  been  used.  These  are  combined  with  powdered  iodo- 
form in  ointment  with  various  greasy  excipients,  or  the  powder  is  rubbed 
into  a  paste  with  glycerine  and  then  scented.  The  misfortune  is  that  the 
odoriferous  principle  is  more  volatile  than  the  iodoform,  and,  aided  by 
the  heat  of  the  body,  soon  leaves  the  odor  of  the  iodoform  supreme.  Ap- 
plications of  iodoform,  dissolved  in  ether  or  chloroform,  have  been  re- 
commended. Their  application  is  painful,  the  solvent  evaporates,  and 
the  odor  exhales  as  strongly  from  the  fine  dust  left  precipitated  over 
the  surface  of  the  ulcer,  as  if  it  had  been  at  first  deposited  there  in  its 
natural  state. 

Still,  iodoform  is  too  good  a  substance  to  be  given  up.  Those  who  do 
not  object  to  the  odor  can  use  it  freely  as  a  powder,  or  rubbed  into  a 
paste  with  glycerine.  Others  may  use  it  undetected  if  their  chancroids 
are  sub-preputial  and  the  prepuce  reasonably  long.  The  sores  must  be 
washed  and  dried.  A  little  fine  iodoform  dust  is  then  taken  upon  a 
narrow  piece  of  card  and  scattered  over  the  ulcerated  surfaces.  The  pre- 
puce must  now  be  carefully  pulled  forward  and  a  piece  of  absorbent 
cotton  placed  in  its  orifice.  No  portion  of  the  iodoform  must  be  allowed 
contact  with  the  clothes  or  the  fingers  of  the  patient.  He  must  be  care- 
ful, upon  urinating,  to  pull  out  the  cotton  gently,  retract  the  prepuce  only 
enough  to  disclose  the  meatus,  and  put  in  a  fresh  piece  of  cotton  immedi- 
ately. He  must  change  his  dressing  frequently,  at  home,  and  use  great 
care  in  his  washings,  not  to  let  the  water  which  has  run  over  the  sores 
touch  any  part  of  his  person  or  of  his  clothing.  By  using  such  pre- 
3 


34  THE    VENEREAL    DISEASES. 

cautions,  the  most  fastidious  patient  may  employ  this  valuable  remedy 
without  betraying  himself. 

The  effect  of  iodoform  upon  chancroids  is  very  striking.  It  fresh- 
ens up  the  surface  wonderfully,  and  greatly  shortens  the  duration  of  the 
sores.  When  it  cannot  be  used,  the  choice  of  a  local  dressing  lies  between 
many  soothing  and  gently  stimulating  applications.  If  the  sores  are  sub- 
preputial,  and  the  prepuce  loose,  it  is  well  always  to  pull  back  the  fore- 
skin, and,  whatever  dressing  is  employed,  to  interpose  a  film  of  moistened 
prepared  lint,  or  dry  bibulous  paper,  or  absorbent  cotton,  in  such  position 
that  it  will  lie  between  the  sores  and  the  healthy  tissues,  when  the  fore- 
skin has  been  replaced. 

When  the  discharge  is  not  profuse,  dry  absorbent  dressings  alone  may 
be  used,  or,  in  addition,  the  ulcers  may  be  sprinkled  with  powdered  oxide 
of  zinc,  or  starch  with  a  little  calomel  (gr.  x.  to  3  i.)>  or  bismuth  and  ly co- 
podium  in  equal  parts.  The  addition  of  a  little  camphor  keeps  the  secre- 
tions sweet.  The  dressings  must  be  changed  often,  and  the  sores  fre- 
quently washed  and  dried.  These  remarks,  be  it  understood,  apply  to 
chancroids  which  may  not  be  burned,  and  where  idoform  is  objectionable 
for  any  reason. 

When  the  discharge  of  pus  is  considerable,  rather  stimulating,  moist 
dressings  are  preferable,  and  lint  slightly  moistened  with  the  fluid  selected 
should  be  kept  constantly  applied  to  the  surface  of  the  ulcer.  Any  of 
the  following  lotions  will  serve  : 

3 .     Zinci  sulph gr.  i. — iij. 

Aquae §  i. 

M. 
Or— 

$.     Potass,  permanganatis gr.  i. — iij. 

Aquae §  i. 

M. 
Or— 

$.     Acid  carbolic gr.  ij. — iij. 

Aquae §  i. 

M. 
Or— 

$.     Ferri  et  potass,  tart gr.  v. — xx. 

Aquae f  i. 

M. 
Or— 

IJ  •     Vini  aromatic 3  i. — iij- 

Aquae q.  s.  ad  f  i. 

M. 

With  sucb  applications  and  patience,  all  uncomplicated  chancroids 
get  well  within  a  reasonable  period.  In  using  No.  2,  4  or  5  of  the  above, 
care  must  be  taken  by  the  patient  not  to  soil  his  linen  ;  the  others  leave 
no  stain. 

Internal  medication  is  of  no  value  in  ordinary  cases  of  chancroid.  If 
the  patient  be  manifestly  debilitated,  he  should  receive  tonics  and  good 
food,  and  all  functional  derangements  demand  appropriate  attention,  but 
there  is  no  internal  specific  for  chancroid.  Rest  of  body  is  sometimes 
desirable. 

If  the  ulcers  prove  very  sluggish,  and  need  spurring  on,  it  is  useful  to 


CHANCROID.  35 

make  an  occasional  application,  directly  to  the  ulcerated  surfaces,  of  bro- 
mine 3  ij-  to  the  §  L,  or  of  pure  carbolic  acid,  or  of  a  saturated  solution 
in  water  of  permanganate  of  potash.  A  thorough  going  over  with  nitrate 
of  silver  will  sometimes  freshen  the  ulcers  up  ;  but  time  is  the  most  effi- 
cient element  in  effecting  a  cure  in  all  ulcers  too  old  for  rapid  cure  by 
thorough  cauterization,  or  where  destructive  measures  have  been  inap- 
plicable from  the  first. 

Anal  and  rectal  chancroids  are  always  obstinate  and  difficult  to 
manage.  The  daily  stretching  of  the  parts  by  the  faeces,  and  the  diffi- 
culty of  maintaining  perfect  cleanliness,  are  the  main  obstacles  to  cure. 

Cauterization  is  inappropriate  for  ulcers  in  this  region.  Frequent 
washings  with  warm  water  containing  chlorinated  soda,  and  confinement  to 
bed,  with  lavish  use  of  iodoform  powder  upon  all  the  ulcerated  surfaces, 
is  unquestionably  the  best  treatment  for  recent  chancroids  in  these  regions. 
Constipation  must  be  prevented.  When  the  chancroid  has  lasted  for  years, 
and  produced  stricture  of  the  rectum,  extirpation  with  the  knife,  linear  rec- 
totomy,  or  lumbar-colotomy,  may  be  required  to  effect  a  cure.  (Bridge's 
case.) 

Chancroids  at  the  margin  of  the  meatus  urinarius  may  be  cauterized 
unless  they  run  too  far  down  into  the  urethra.  In  such  case  iodoform 
plugs  (a  roll  of  lint  covered  with  cerate  and  sprinkled  with  iodoform)  will 
hasten  cure.  If  the  patient  objects  to  this,  he  must  wait  long  for  nature 
to  help  him,  for  chancroids  in  this  locality  are  very  sluggish.  Urethral 
chancroids  are  best  let  alone.  They  are  very  rare,  and  their  ultimate 
effect  is  stricture  of  the  urethra. 

Sub-preputial  chancroid  implies  a  chancroid  concealed  by  a  pre- 
puce, either  congenitally  tight,  so  that  it  cannot  be  retracted,  or  in  a 
state  of  temporary  phymosis  from  inflammation.  The  latter  condition 
will  be  discussed  under  the  head  of  Complications  (p.  37). 

When  a  chancroid  is  inside  of  a  congenitally  contracted  foreskin,  its 
presence  can  sometimes  only  be  surmised.  Generally  a  lump,  tender  on 
pressure,  may  be  detected  at  one  spot,  however,  or  there  may  be  several 
of  them;  and  the  auto-inoculability  of  the  pus,  and  possible  existence  of 
chancroids  at  the  margin  of  the  prepuce,  help  to  make  the  diagnosis. 

In  treating  such  chancroids,  if  the  prepuce  be  not  inflamed  and  in 
danger  of  strangulation,  it  is  not  necessary  to  use  the  knife.  No  exten- 
sive destruction  of  the  parts  within  the  prepuce  is  apt  to  occur  unaccom- 
panied by  such  external  evidences  of  destructive  inflammation  as  will 
naturally  call  for  heroic  interference. 

Cleanliness  is,  if  possible,  more  necessary  in  treating  these  chancroids 
than  any  others.  A  syringe  with  a  long,  flattened  nozzle l  should  be 
used,  its  point  inserted  well  down  to  the  sulcus  behind  the  corona,  and 
into  the  pockets  on  either  side  of  the  frenum.  Warm  injections  of  the 
one-half  of  one  per  cent,  solution  of  carbolic  acid  should  be  made  fre- 
quently enough  to  keep  the  pus  from  accumulating.  Ricord  praises  the 
occasional  injection  of  a  gr.  v. — xv.  solution  of  nitrate  of  silver.  Iodoform 
shaken  up  with  balsam  of  Peru  may  be  injected  into  the  depths  of  the 
preputial  cavity  with  a  syringe.  Generally,  these  chancroids  are  slow, 
and  cleanliness,  with  time,  the  only  real  elements  in  the  cure. 

Chancroids  of  the  margin  of  the  prepuce,  there  being  no  ulcers 
within,  if  they  can  be  thoroughly  exposed,  should  be  cauterized. 

Chancroids  undermining  the  frenum  call  for  a  division  of  the  frenum, 

1  Such  a  syringe  has  been  devised  by  Dr.  R.  W.  Taylor,  of  New  York. 


36  THE    VENEREAL   DISEASES. 

to  hasten  their  cure  and  avert  the  possibility  of  bleeding,  should  the  fre- 
num  get  accidentally  ruptured  or  eaten  through  by  ulceration.  This  is 
best  accomplished  by  tying  a  stout  silken  ligature  around  it,  and  cutting 
the  ligature  short.  The  ligature  cuts  its  own  way  through  very  promptly, 
and  then  the  open  chancroid  may  be  treated  more  satisfactorily. 

Chancroids  of  the  vulva  and  vagina  call  for  especial  care.  Cau- 
terization, if  applied,  must  be  done  with  great  accuracy  and  thoroughness, 
with  the  parts  fully  exposed.  The  speculum  must  always  be  used,  and 
the  whole  of  the  interior  of  the  vagina  inspected  for  other  ulcers,  or  cau- 
terization of  the  chancroid  of  the  fourchette,  or  elsewhere,  is  apt  to  be 
ineffective.  Young  chancroids  anywhere  about  the  female  genitals  (ex- 
cept at  the  orifice  of  the  urethra)  may  be  successfully  cauterized  ;  old 
ones  are  best  treated  with  cleanliness,  disinfectant  injections,  rest,  and 
iodoform.  lodoform  may  be  easily  so  managed  upon  a  female  as  not  to 
be  offensive  in  odor.  Follicular  chancroids  on  the  labia  majora,  at  the 
roots  of  the  hairs,  are  not  very  unusual  in  woman.  They  look  like  boils 
at  first.  They  should  never  be  poulticed,  but  opened  very  early,  and 
cauterized  thoroughly. 

The  external  genitals  in  the  female  sometimes  become  greatly  hyper- 
trophied  from  the  prolonged  presence  of  chancroids  at  the  ostium  vaginae. 
Treatment  of  the  hypertrophy  is  useless  until  the  chancroids  are  cured, 
after  which  it  usually  slowly  subsides  spontaneously.  Traces  of  it  may 
remain  almost  indefinitely. 

Chancroid  of  the  fingers. — When  the  surgeon  or  accoucheur  gets  a 
chancroid  upon  the  finger,  it  should  be  thoroughly  cauterized,  and  then 
splinted,  and  kept  covered  up  from  dust  and  exposure  to  air.  A  chan- 
croid on  a  knuckle  is  sometimes  as  hard  to  cure  as  a  chancroid  of  the 
anus  or  at  the  meatus  urinarius,  the  reason  being  that  the  incessant  in- 
jury done  by  motion  of  the  part  keeps  the  ulcer  alive.  An  ordinary 
abrasion  will  sometimes  ulcerate,  and  last  for  weeks  upon  a  knuckle.  I 
have  known  one  such  abrasion  to  be  diagnosticated  as  a  syphilitic  chancre, 
and  the  patient  kept  miserable  for  years,  fearing  syphilitic  eruptions 
which  never  came.  A  splint  putting  the  knuckle  at  rest  is  all  the  special 
treatment  that  is  required  in  these  cases. 


CHAPTER  IV. 

CHANCROID. 

THE  COMPLICATIONS  OF  CHANCROID,  AND  THEIR  TREATMENT. 

Chancroid  complicated  by  Inflammation.' —Inflammatory  Phymosis  and  Paraphymo- 
sis,  with  their  Treatment. — Phagedsena,  Sloughing  and  Serpiginous,  and  its 
Treatment. — Chancroid  complicated  by  Syphilis. — The  Lymphangitis  of  Chan- 
croid, Inflammatory  and  Virulent,  and  its  Treatment. — The  Bubo  of  Chancroid, 
Simple,  Indolent,  Spontaneous  (Bubon  d'Emblee). — Treatment  of  Simple  Bubo. — 
Treatment  of  Indolent  Bubo. — Virulent  Bubo,  or  Subcutaneous  Chancroid. — 
Treatment  of  Virulent  Bubo. 

CHANCROID  may  be  complicated  by  inflammation,  phagechena,  syphilis, 
lymphangitis,  and  bubo. 

Chancroid,  complicated  by  inflammation. — An  ulcer  doubtless 
cannot  exist  without  some  inflammation,  but  a  typical  chancroid  is  at- 
tended by  so  little  of  this  process  that,  practically,  inflammation  does  not 
exist;  certainly  there  is  no  pain,  heat,  redness,  swelling,  or  interference 
with  function  worthy  of  being  taken  into  account.  Most  chancroids, 
however,  as  encountered  clinically,  are  inflamed  in  a  measure,  and  possess 
all  the  five  qualities  of  inflammation  to  a  greater  or  less  extent.  This 
amount  of  inflammation  does  not  constitute  a  complication. 

When  a  chancroid  inflames  from  mechanical  or  chemical  irritation,  or 
from  the  habits  of  the  patient  (drinking,  debility),  its  base  hardens,  its 
discharge  grows  thinner  and  sanious,  pain  is  complained  of,  and  generally 
the  course  of  the  sore  is  prolonged,  the  surrounding  tissues  becoming 
cedematous  and  indurated,  and  the  ulcer  finally  pale,  flabby,  unhealthy, 
going  on  to  a  slow  cicatrization.  Simple  (non-virulent)  bubo  is  very  much 
more  apt  to  occur  with  an  inflamed  chancroid  than  with  a  typical  ulcer. 

When  inflammation  complicates  sub-preputial  chancroid,  the  tissues 
of  the  prepuce  become  much  distended  with  serum,  and  sometimes  very 
hard  and  rigid  from  stiffening  of  the  connective  tissue  by  inflammatory 
exudation.  A  superficial  lymphangitis  is  the  cause  of  these  phenomena; 
the  larger  lymphatic  vessels  may  escape  entirely.  This  lymphangitis  is 
not  an  erysipelas,  although  it  greatly  resembles  it.  It  is  not  an  uncom- 
mon complication  of  chancroid,  while  true  erysipelas  is  a  rare  one. 

Inflammatory  phymosis  or  paraphymosis,  under  these  circumstances, 
often  ensue.  If  the  chancroid  occupies  the  inner  surface  of  the  prepuc'e, 
it  is  in  danger  of  strangulation  among  the  inflamed  tissues,  and  may  fall 
into  total  gangrene,  a  large  portion  of  the  prepuce,  with  the  chancroid, 
sloughing  away,  and  allowing  the  glans  penis  to  protrude  through  the 
opening,  making  a  sort  of  double-headed  penis.  The  remains  of  the  pre- 
puce in  such  cases  long  continue  thickened  and  indurated,  and  require  to 
be  trimmed  away  finally,  when  cicatrization  is  complete. 

This  result  of  inflammation  is  not  a  serious  one,  since  the  sloughing 


38  THE   VENEREAL   DISEASES. 

process  kills  the  chancroid  outright  and  repair  commences  with  the  sepa- 
ration of  the  slough,  just  as  it  does  after  effective  cauterization. 

A  more  disastrous  result  of  inflammatory  phymosis  is  the  possibility 
of  many  new  points  of  auto-inoculation  within  the  cavity  of  the  prepuce, 
the  retained  poisonous  pus  excoriating  the  surface  of  the  glans  penis  and 
perhaps  inoculating  the  meatus.  Portions  of  the  new  chancroids  may 
then  slough,  and  considerable  loss  of  the  glans  penis  ensue,  with  stricture 
of  the  meatus  from  cicatrization.  The  liability  of  causing  bubo  by  allow- 
ing an  inflamed  prepuce  over  a  chancroid  to  remain  long  unrelieved  is  to 
be  borne  in  mind,  and  the  possibility  of  extensive  denudation  of  the  penis 
by  the  backward  burrowing  of  the  retained  chancroidal  pus  has  been  clin- 
ically proved  (Vidal). 

Inflammatory  paraphymosis  may  complicate  a  chancroid  when 
the  prepuce  is  short.  The  swelling  encircling  the  penis  may  become  so 
great  that  the  circulation  of  that  portion  of  the  penis  lying  in  front  of  the 
constriction  is  menaced. 

The  treatment  of  inflammatory  complications  of  chancroid  is  obvi- 
ous. Rest  must  be  insisted  upon,  the  penis  elevated  and  covered  with 
moist,  cooling,  evaporating  lotions,  or  with  astringent  solutions.  Among 
the  former,  one  of  the  best  is: 


]J.  Glycerine 

Spts.  rect  .....................................   3  i.  —  ij. 

Liquor,  plumbi  sub-acetat.  dil  ...........   q.  s.  ad  |  i. 

M. 

It  is  to  be  kept  constantly  applied  cold  upon  a  thin  cloth  on  the  outside 
of  the  penis. 

Solutions  of  tannin  act  exceedingly  well  as  astringents  in  some  con- 
ditions of  cedema  of  the  penis.  The  main  objection  to  it  is  that  it  stains 
white  fabrics.  From  gr.  x.  —  xx.  in  ^  i.  of  water  is  strong  enough.  It 
must  be  constantly  applied  fresh,  and  the  penis  kept  well  elevated. 

These  applications  are  palliative.  The  treatment  of  the  chancroid, 
meantime,  goes  on  by  sub-preputial  injections,  idoform  applications,  or 
whatever  it  may  be.  If  the  sub-preputial  discharge  of  pus  gains  in  quan- 
tity, if  the  inflammation  fails  to  yield  and  gangrene  is  to  be  feared,  then 
but  one  course  is  left,  namely:  to  slit  open  the  cavity  of  the  prepuce^ 
cut  away  the  redundant  tissue,  circumcising  the  patient,  and  dress  un- 
sparingly with  iodoform.  Cauterization  in  these  cases  will  not  prevent 
the  wound  from  becoming  inoculated,  and  only  prolongs  the  duration  of 
the  sore. 

In  cases  of  paraphymosis  the  line  of  stricture  of  the  prepuce  must  be 
divided  with  the  knife  as  soon  as  the  circulation  of  the  penis  in  front  of 
it  is  threatened.  If  the  circulation  continues  perfect  it  is  better  in  most 
cases  not  to  attempt  to  reduce  the  paraphymosis,  since  the  latter  insures 
the  advantage  of  leaving  the  ulcers  exposed  to  view.  A  patient  with  para- 
phymosis is  generally  confined  to  bed,  and  the  odor  of  iodoform  ceases  to 
be  an  objection  to  its  use. 

Chancroid  complicated  by  phagedaena.—  This  is  the  most  formid- 
able of  all  the  local  complications  of  chancroid.  Phagedeena  occurs  in 
two  forms:  (1),  sloughing  phagedaena;  (2),  serpiginous  phagedaena.  The 

disposing  general  causes  of  phagedaena  are  not  fully  known.  It  some- 
times attacks  a  florid,  healthy-looking  youth,  and  often  spares  a  cadaver- 
ous consumptive,  or  a  patient  debilitated  by  excesses  of  all  sorts.  It  is  a 


CHANCROID.  39 

rare  complication.  Phagedaena  is  not  confined  to  chancroids.  Any  ulcer — 
syphilitic,  scrofulous,  or  simple — may  be  attacked  by  it.  Phagedaena  is  a 
peculiar  quality  of  the  individual.  The  pus  from  a  phagedenic  ulcer  will 
not  produce  phagedaena  by  hetero-inoculation.  This  has  been  abundantly 
proved  by  Fournier's  confrontations,  Sperino's  syphilization,  the  inocula- 
tions of  Salneuve,  Rollet,  and  others.  Conversely,  it  is  known  that  a  sim- 
ple chancroid  produced  upon  a  patient  with  phagedaena  is  liable  also  to 
become  phagedenic,  showing  clearly  that  the  phagedenic  quality  is  a  per- 
sonal one. 

Among  the  presumed  predisposing  causes  of  phagedaena  have  been 
grouped  all  depressing  dietetic,  hygienic,  diathetic  and  pathological  con- 
ditions— old  age,  misery,  alcoholism,  scrofula,  malaria,  digestive  troubles 
— but  not  one  of  these  can  be  proved  efficient  even  in  a  majority  of  cases. 
As  local  causes,  lack  of  cleanliness  and  mercurial  ointment  (Ricord)  have 
been  accredited  with  a  fair  share  of  the  blame  in  the  production  of  pha- 
gedaena, but  probably  without  good  ground  for  the  accusation.  It  is  prob- 
able that  phagedaena  is  a  personal  idiosyncrasy,  perhaps  allied  to  the 
scrofulous  diathesis  (but  independent  of  it),  not  existing  continuously  in 
a  given  patient,  and  aggravated  by  those  causes  which  have  generally  been 
considered  capable  of  generating  it.  No  other  explanation  than  this  cov- 
ers the  cases  of  bright-eyed,  rosy-cheeked,  fat,  hearty  boys,  with  good 
appetites,  strong  physical  powers,  and  in  the  healthy  performance  of  their 
functions — with  phagedasna.  I  have  encountered  several  cases  of  this  sort. 
On  the  other  hand,  who  has  not  met  with  broken-down  patients  with 
syphilis,  consumption,  cancer,  malaria,  fever,  cachexia,  old  age,  dyspep- 
sia, whose  chancroids  belong  to  the  simplest  possible  type  and  run  their 
course  mildly  in  a  reasonable  time. 

Sloughing  phagedaena. — When  a  chancroid  is  attacked  by  sloughing 
phagedaena  the  tissues  beneath  it  swell  up  and  become  livid  for  a  distance 
around.  The  pus  gets  scanty  and  sanious.  The  ulcer  grows  larger  and 
dryer;  a  slough,  gray,  brown,  black,  promptly  forms  upon  it;  the  part  be- 
comes excessively  painful;  the  slough  separates  promptly,  or  slowly,  ac- 
cording to  its  thickness;  and  then  comes  a  lull  in  the  process. 

After  a  rest  of  longer  or  shorter  duration  a  new  attack  of  pain  an- 
nounces the  commencing  formation  of  a  new  slough,  and  the  process  re- 
peats itself.  Large  excavations  in  the  tissues  are  thus  caused,  for  slough- 
ing phagedaana  spares  nothing.  It  does  not  dissect  out  the  vessels  or  ar- 
rest itself  at  a  barrier  formed  by  a  new  tissue.  Fortunately,  it  generally  re- 
mains superficial  and  advances  on  one  side  while  it  gets  well  on  the  other. 
This  is  not  always  the  case.  It  may  sweep  away  the  penis  in  the  male, 
destroy  the  labia  and  perineum  in  the  female,  make  the  most  extensive 
ravages  before  its  fury  is  appeased.  It  has  been  compared  to  hospital 
gangrene,  which  it  much  resembles.  It  may  even  endanger  life  by  excit- 
ing peritonitis  when  ulcerating  deeply  over  the  abdomen,  or  giving  rise  to 
profuse  haemorrhage  by  cutting  through  a  blood-vessel.  It  may  wear 
out  the  sufferer  by  pain,  fever,  exhausting  diarrhoaa,  and  debilitating 
sweats. 

The  poisonous  chancroidal  quality  of  these  ulcers  remains  as  tested 
by  inoculation,  yet  the  poisoned  surface  seems  to  grow  tolerant  of  the 
virus  after  a  time,  and  one  side  of  the  great  ulcer  will  be  cicatrizing, 
while  a  fresh  slough  is  forming  on  its  opposite  border. 

Serpiginous  (creeping)  phagedaena. — This  form  of  phagedaena  is 
milder  in  all  respects  than  the  sloughing  variety,  but,  in  revenge,  it  is  more 
chronic.  The  former  exhausts  itself,  yields  to  treatment,  or  kills  the  pa- 


40  THE    VENEREAL   DISEASES. 

tient  within  a  reasonable  period,  while  creeping  phagedana  seems  to  have 
little  or  no  reaction  upon  the  general  health,  is  not  attended  by  much 
pain  or  any  fever,  and  yet  continues  sometimes  almost  indefinitely.  The 
longest  duration  for  a  phagedenic  chancroid  yet  recorded  is  fourteen 
years.  This  case  is  reported  by  Fournier,  the  phagedaena  commenced  in 
a  virulent  bubo  at  the  groin,  and  was  still  open  at  the  knee  when  reported 
by  Fournier  several  years  ago.  Its  duration  was  not  due  to  bad  treat- 
ment, for  Ricord  had  had  the  patient  under  his  care  for  several  years. 

The  nature  of  the  creeping  phagedsena  is  not  known  any  more  than 
that  of  sloughing  phagedaena.  All  that  can  be  said  is,  that  it  is  not  trans- 
mitted by  hetero-inoculation,  and  generally  occurs  upon  the  debilitated. 
The  lower  orders  of  society  furnish  most  of  the  cases  for  hospitals.  Among 
the  upper  classes  it  is  seldom  seen,  except  in  its  mildest  form,  which  con- 
sists simply  in  an  unusual  spread  in  the  area  of  the  ulcer,  some  deviation 
from  the  rounded  shape,  and  a  certain  prolongation  of  the  duration  of  the 
sore. 

Serpiginous  phagedfena  commences  as  a  swelling  at  the  borders  of  the 
chancroid,  which  become  more  red  than  usual.  Some  headache  may  be 
complained  of,  and  a  burning  sensation  at  the  advancing  edge  of  the 
ulcer.  The  connective  tissue  falls  into  molecular  gangrene  more  readily 
than  the  fibrous  felting  of  the  cutis  vera,  and,  as  a  consequence,  the  bor- 
ders of  the  ulcer  become  largely  undermined.  The  remaining  bridges 
and  their  flaps  of  livid  skin,  perforated  here  and  there  where  the  ulcera- 
tive  action  has  eaten  through  to  the  surface,  make  pockets  and  sinuses 
around  the  ulcer,  some  of  which  extend  to  long  distances.  In  this  manner 
all  the  integument  of  the  penis  may  be  dissected  up,  large  pouches  run 
down  the  thigh  and  around  the  crest  of  the  ilium,  or  (more  rarely)  up  over 
the  abdomen. 

As  one  side  of  the  ulcer  advances  the  other  generally  heals,  and  thus 
the  ulcer  creeps  for  months,  perhaps  for  years,  over  the  surface.  The  base 
of  the  sore  retains  its  chancroidal  character.  It  is  uneven,  gray,  covered 
with  adherent,  pultaceous  secretions,  and  occasional  prominent,  flabby 
granulations  bleeding  at  the  slightest  touch.  The  discharge  is  watery, 
bloody,  usually  free,  occasionally  scanty,  but  still  auto-inoculable. 

Periods  of  rest  of  greater  or  less  length  occur  during  the  progress  of 
phagedsena,  when  the  ulcer  remains  stationary,  or  even,  perhaps,  seems 
to  be  healing  all  around;  arid  then,  without  apparent  cause,  the  phage- 
denic action  will  commence  again  at  one  border,  while  cicatrization  goes 
slowly  on  undisturbed  at  the  other. 

Phagedaena  once  seen  cannot  afterward  be  confounded  with  anything 
else.  Its  attacks  are  not  limited  to  chancroid,  but  are  also  seen  in  the 
serpiginous  ulcerative  scrofulide  or  syphilide.  In  any  case  of  doubt,  diag- 
nosis must  rest  upon  the  history  of  the  origin  of  the  process  (in  a  chan- 
croid or  virulent  bubo),  and  upon  the  auto-inoculability  of  the  pus. 

The  bubo  attending  phagedenic  chancroid  may  be  a  simple  one,  or  may 
be  virulent,  and  itself  take  on  phagedenic  action.  Phagedaena  seldom,  if 
ever,  attacks  simple  inflammatory  bubo. 

Serpiginous  phagedaena  never  gets  beneath  the  deep  fascia  ;  a  change 
of  tissue  will  often  stop  it,  and  it  will  dissect  out  nerves  and  vessels,  leaving 
them  exposed  in  the  wound;  it  is  generally  arrested  at  mucous  membranes. 
Unless  commencing  in  the  vagina,  it  rarely  enters  it,  and  does  not  enter 
e  rectum  from  without.  In  both  of  these  localities,  especially  the  va- 
gina, it  may  thrive  and  last  for  years  ;  but  in  these  cases  it  has  originated 
in  a  chancroid,  upon  the  mucous  surface,  and  has  not  commenced  outside, 


CHANCROID.  41 

— as  phagectaena  in  a  bubo,  for  instance, — and  worked  its  way  from  the  in- 
tegument into  the  vagina. 

Treatment  of  phagedaena. — All  possible  improvement  in  the  hygie- 
nic surroundings  of  a  patient,  a  generous  and  varied  diet,  and  internal 
tonic  measures,  are  of  value  in  treating  phagedsena.  Cod-liver  oil,  if  it 
can  be  digested,  quinine  in  large  doses,  especially  in  the  depressing  fever 
of  sloughing  phagedsena,  and  iron,  are  excellent  remedies.  Custom  has 
sanctioned  the  preference  of  Ricord's  tartrate  of  iron  and  potash,  in  ten 
to  twenty  grain  doses  in  solution,  as  a  tonic  in  phagedaena.  Ricord 
thought  it  was  nearly  a  specific,  and  some  cases  certainly  do  well  upon  it. 

The  internal  treatment  of  phagedaena  by  opium  will  sometimes  suc- 
ceed, especially  in  old  cases  of  serpiginous  sore,  where  there  is  more  pain 
than  usual.  Some  surgeons  place  much  reliance  upon  opium  in  all  condi- 
tions of  chronic  ulcer.  Rodet  reports  cases  of  serpiginous  chancroids, 
which  got  well  under  opium,  after  other  means  had  failed.  The  solid 
opium  (or  an  extract)  is  given  in  small  and  repeated  doses,  gradually  in- 
creased as  the  patient  acquires  tolerance,  and  pushed  to  the  point  of  keep- 
ing him  slightly  narcotized  all  the  time.  If  good  effect  is  to  follow,  it 
•commences  within  a  week  or  ten  days.  The  objections  to  the  treatment 
are  the  constipation  it  occasions,  to  be  met  by  the  use  of  appropriate  lax- 
atives given  with  the  opium,  and  the  possible  danger  of  establishing  the 
opium-habit. 

The  local  treatment  is  more  important  than  general  measures.  It 
must  be  remembered  that  a  chancroid  never  commences  phagedenic.  It 
exists  as  a  chancroid  for  a  varying  time,  and  then  takes  on  phagedsena. 
A  chancroid  by  auto-inoculation  upon  a  person  with  phagedasna  acts  in 
this  way,  and  the  advantage  of  early  and  thorough  destruction  of  all  chan- 
croids becomes  on  this  account  very  evident. 

Both  forms  of  phagedtena  require  the  same  local  treatment.  They 
should  be  managed  like  cases  of  hospital  gangrene.  Total  destruction  of 
all  the  tissues  involved,  and  extending  widely  beyond  the  immediate  area 
of  disease,  is  certainly  the  best  treatment.  This  cauterization  must  be  a 
severe  one.  It  will  not  destroy  more  tissue  than  the  ulcer  left  to  itself 
would  have  eaten  away,  and  an  imperfect  cauterization  will  do  more  harm 
than  good. 

Ether  should  always  be  administered  in  these  cases.  The  ulcer  must 
first  be  ready  for  cauterization.  All  overhanging  bridges  and  flaps  of  un- 
•dermined  livid  integument  must  be  cut  away.  It  is  best  to  do  this  with 
scissors,  and  to  sear  the  bleeding  edges  at  once  with  a  thermo-cautery 
(such  as  Paquelin's).  When  all  sinuses  have  been  laid  open,  and  the 
whole  ulcer  is  flat  and  exposed  and  the  bleeding  arrested,  then  the  sur- 
face should  be  washed  with  a  solution  of  carbolic  acid,  and  dried  with 
bibulous  paper.  Next,  it  should  be  touched  all  over  with  pure  carbolic 
acid.  This  whitens  the  surface,  but  leaves  it  soft,  and  it  may  be  dried, 
and  left  quite  clean  and  white,  ready  for  the  final  cauterization. 

Nitric  acid  cannot  be  depended  upon  in  burning  these  extensive  ulcers. 
A  certain  depth  beneath  the  ulcer  must  be  destroyed  in  all  directions,  in 
order  that  the  cauterization  may  prove  effective.  As  the  floor  of  the  ulcer  is 
uneven,  a  liquid  caustic  cannot  be  applied  uniformly  over  the  whole  sur- 
face ;  it  will  spare  the  elevations,  and  spend  its  force  upon  the  depressions. 
There  is  no  reason  why,  if  accurately  applied,  nitric  acid  should  not  serve 
as  well  here  as  any  caustic ;  but  the  difficulty  is  mechanical,  and  other 
caustics  are  better. 

The  choice  of  caustic  lies  between  actual  cautery  and  a  caustic  paste, 


42  THE    VENEREAL   DISEASES. 

Hot  irons  do  not  cauterize  well,  because  they  give  up  their  heat  very 
promptly,  and,  therefore,  cauterize  unevenly.  The  electro-cautery  is  bet- 
ter, or  the  naphtha  cautery  of  Paquelin,  because  the  cautery  point  can 
be  kept  uniformly  hot  throughout  the  entire  sitting,  no  matter  how  pro- 
longed the  latter  may  be.  By  the  use  of  these  means,  employed  with 
the  utmost  deliberation  and  care,  if  the  entire  base  and  the  surrounding 
integument  for  one-fourth  of  an  inch  can  be  absolutely  charred  by  the 
cautery,  nothing  more  can  be  asked,  and  a  cure  of  the  phagedaena  may  be 
confidently  expected. 

Unfortunately,  but  few  phagedenic  sores  are  sufficiently  small,  or  so  sit- 
uated as  to  be  certainly  totally  destroyed  in  this  manner  without  endanger- 
ing surrounding  parts.  In  such  case,  if  the  ulcer  is  suitable  for  cauteriza- 
tion at  all,  a  caustic  paste  should  be  employed.  Either  the  chloride  of  zinc, 
or  the  carbo-sulphuric  paste  may  be  used — preferably  the  former,  freshly 
prepared,  by  mixing  equal  parts  of  chloride  of  zinc  and  dried  flour,  with  a 
few  drops  of  alcohol,  into  a  paste.  This  is  to  be  packed  and  crowded  into 
all  the  uneven  crevices  and  irregularities  of  the  surface  already  prepared, 
as  directed  above,  and  thoroughly  dried  out.  The  packing  is  done  with 
a  small  wooden  spatula,  and  the  excavation  of  the  ulcer  filled  in  even  with 
the  surface  of  the  surrounding  integument  at  the  edges,  but  not  laid  on, 
thicker  at  any  one  spot  than  one-eighth  of  an  inch,  since  this  thickness  is 
ample.  The  packing  is  now  accurately  covered  with  a  piece  of  prepared 
lint  cut  to  fit,  the  surrounding  epidermis  is  greased  with  vaseline  freely, 
then  the  whole  surface  is  generously  dusted  with  powdered  starch  or  lyco- 
podium,  covered  with  a  thick  layer  of  absorbent  cotton,  the  whole  retained 
by  a  snug  roller-bandage. 

Morphine  may  be  required  to  control  pain.  The  bandages  should  be 
removed  in  from  twelve  to  twenty-four  hours,  the  surface  washed,  and 
dried  with  absorbent  cotton,  and  finally  dressed  with  a  mildly  carbolized 
water  dressing,  or  any  other  simple  application. 

Bromine  has  been  suggested  for  these  ulcers,  and  a  saturated  solution 
of  permanganate  of  potash,  but  neither  of  these  means  have  been  generally 
enough  employed  to  justify  a  conclusion  as  to  their  exact  value.  The 
methods  above  detailed  are  certainly  efficient  where  cauterization  is  justi- 
fiable. 

There  are  many  cases  of  bad  phagedaena  in  which  cauterization  should 
not  be  attempted.  In  any  case,  when  the  whole  surface  cannot  be  laid 
bare  and  included  in  one  cauterization,  other  means  must  be  used.  This 
exception  covers  many  cases  of  vaginal  and  rectal  phagedasna — cases  in 
which  such  extensive  layers  of  integument  have  been  dissected  up,  that 
it  becomes  unsurgical  to  remove  them,  e.  ff.,  when  the  integument  of  the 
penis  is  very  much  undermined,  cases  in  which  long  sinuses  exist  involv- 
ing too  extensive  destruction  of  tissue.  Finally,  cauterization  is  not  ap- 
plicable when  there  is  danger  that  the  caustic  may  do  harm  by  eating  in 
too  deeply;  on  this  account,  extensive  and  deep  phagedaena  over  the 
femoral  vessels,  which  would  stay  the  hand  of  the  operator  through  fear 
>f  going  too  deeply,  is  not  a  proper  case  for  caustic.  Finally,  if  thorough 
snzation  has  once  failed,  it  is  better  to  try  other  means  before  resort- 
ing to  it  again,  and  under  these  circumstances  the  occasional  application 

the  lighter  caustics,  carbolic  acid,  bromine,  saturated  solution  of  per- 
manganate of  potash,  have  a  place,  and  doubtless  will  freshen  up  the  sur- 
face and  help  to  cure  in  many  cases  where  thorough  cauterization  cannot 
be  applied,  or  has  failed. 

n  here   cauterization   is   not   applicable,  pure  powdered  iodoform  is. 


CHANCROID.  43 

incomparably  the  best  local  application.  The  ulcer  should  be  covered 
with  iodoform  dust,  which  is  to  be  renewed  as  often  as  the  discharges 
wash  it  away.  This,  with  disinfecting  washes  of  weak  carbolic  acid  or 
weak  chlorinated  soda-water,  is  an  excellent  resource,  and  often  acts  like 
a  charm.  Ricord's  old  favorite  as  a  local  application,  gr.  xx. — xl.  solu- 
tion of  tartrate  of  iron  and  potash,  must  not  be  forgotten. 

An  attack  of  ordinary  erysipelas  passing  over  a  phagedenic  chancroid 
sometimes  cures  it  entirely. 

The  method  of  treating  phagedenic,  syphilitic,  and  other  unhealthy 
sores,  by  intermitted  or  continuous  submersion  in  water,  has  been  revived 
of  late,  and  brought  into  prominence  through  the  publication,  by  Mr. 
Arthur  Cooper,1  of  some  exceptionally  good  results  obtained  by  its  use  in 
the  Lock  Hospital,  upon  patients  under  the  care  of  Mr.  Alfred  Cooper 
and  of  Mr.  Milner. 

This  treatment  is  not  at  all  new.  The  names  of  Hebra  in  Germany, 
Hutchinson  in  England,  and  Hemard  in  France,  are  well  known  in  con- 
nection with  it;  but  the  supposed  difficulty  in  carrying  out  the  process, 
a  lack  of  widespread  conviction  in  its  superior  value,  and  the  fact  that 
text-books  do  not  commonly  advise  this  form  of  treatment,  have  kept  it 
out  of  general  use,  and  prevented  it  from  being  tested  on  a  large  scale. 
It  is  time  that  this  apathy,  regarding  what  promises  to  be  an  excellent 
method,  should  come  to  an  end.  The  reliable  results  which  have  been 
published  certainly  render  the  method  worthy  of  trial  in  all  severe  cases 
of  phagedaena,  whether  attacking  chancroid,  chancroidal  bubo,  or  a  syphi- 
litic sore. 

The  method  of  submersion  employed  by  Mr.  Cooper  is  simple  and 
easy  to  carry  out,  while  its  effectiveness  can  hardly  be  doubted  after  read- 
ing the  report  of  the  cases  in  which  it  was  used.  Briefly,  the  method  is 
as  follows: 

The  patient  is  made  to  sit  in  a  hip-bath,  or  other  convenient  bath,  so 
that  the  site  of  the  ulcer  may  be  entirely  submerged  for  from  eight  to 
ten  hours  a  day.  The  water  is  kept  as  nearly  as  possible  at  a  uniform 
temperature  of  98°  F.  A  blanket  over  the  shoulders,  and  another  (or  a 
rubber  air-cushion)  between  the  buttocks  and  back  and  the  cold  tub, 
complete  the  apparatus.  Here  the  patient  quietly  remains  all  day.  In 
the  evening  finely  powdered  iodoform  or  other  suitable  dressing  is  put 
upon  the  sore,  and  the  patient  goes  to  bed. 

On  the  following  morning  the  patient  enters  his  bath  without  disturb- 
ing the  dressing  of  his  local  ulcer.  The  water  of  the  bath  thoroughly 
soaks  these  dressings  and  removes  them  without  pain. 

A  purge  before  the  course  of  baths,  and  a  continuance  of  tonics,  and 
any  appropriate  internal  medication  during  their  use,  is  recommended. 

Cooper's  paper  reports  thirty-one  cases.  Of  these,  twenty-two  were 
sloughing  or  phagedenic  ulcers  of  the  penis,  which  had  been  in  existence 
from  a  few  days  to  several  weeks  before  treatment  was  commenced.  The 
remaining  sores  were  phagedenic,  tertiary  syphilitic,  and  gangrenous 
lesions,  involving  the  genitals  or  their  neighborhood.  In  none  of  the 
cases  was  the  bath  used  longer  than  twelve  days;  in  most  of  them  the 
ulcer  is  reported  to  have  become  healthy  in  from  two  to  six  days.  Some 
excellent  cases  are  detailed,  showing  the  rapidly  favorable  influence  of 
the  submersion. 

Three  cases  of  the  "slowly  spreading  non-inflammatory  form  of  phage- 

1  London  Lancet,  May  24,  1879,  p.  731. 


44  THE   VENEREAL    DISEASES. 

<l;i'na  "  are  reported  by  Mr.  Cooper  as  having  relapsed  after  a  discontinu- 
ance of  the  baths.  The  writer  believes  that  this  was  due  to  too  short  a 
continuance  of  the  submersion  treatment. 

Only  three  failures  were  reported:  one  refused  to  continue  the  bath 
after  nine  days;  number  two  was  too  fat  to  sit  comfortably  in  the  bath; 
in  number  three,  the  bath  aggravated  the  pain  of  an  extensive  tertiary 
ulcer;  usually  pain  is  relieved  by  the  bath. 

If  the  sore  is  sub-preputial,  circumcision  should  be  performed.  It  is 
stated  that  the  wound  "  scarcely  ever  takes  on  the  diseased  action."  The 
bath  should  be  continued  at  least  a  day  after  the  wound  looks  quite 
healthy,  and  continuous  submersion,  as  recommended  by  Hutchinson, 
tried  when  intermittent  treatment  fails. 

Chancroid  complicated  by  syphilis. — Chancroid  is  not  said  to  be 
complicated  by  syphilis  when  a  patient  with  syphilis  gets  chancroid.  The 
term  is  applied  only  to  the  mixed  chancre,  where  both  poisons  exist  at  one 
and  the  same  time  in  the  local  sore.  This  ulcer  will  be  described  at  p. 
87.  The  previous  existence  of  syphilis  in  a  patient  does  not  at  all 
modify  the  appearance  or  course  of  chancroid. 


THE   LYMPHANGITIS    OP   CHANCBOID. 

About  two-thirds  of  all  chancroids  remain  purely  local;  the  other  third 
is  attended  by  bubo,  which  latter  may  be  inflammatory  and  resolve,  or 
suppurate,  or  be  virulent.  What  proportion  of  chancroids  is  attended  by 
lymphangitis  is  not  known,  but  it  certainly  is  less  than  one-third.  The 
lymphatic  trunks  rarely  become  implicated  without  simultaneous  bubo, 
while  bubo  frequently  occurs  when  there  is  no  lymphangitis. 

Lymphangitis  attending  chancroid  is  of  two  varieties:  inflammatory 
and  virulent. 

Inflammatory  lymphangitis. — In  this  affection,  one  or  more  of  the 
lymphatic  trunks  upon  the  back  or  sides  of  the  penis  becomes  thickened, 
mainly  by  inflammation  of  the  connective  tissue  surrounding  the  vessel. 
A  hard  cord  is  felt  under  the  skin,  with  perhaps  several  knotty  swellings 
along  its  course,  usually  sensitive  to  pressure,  sometimes  adherent  to  the 
skin,  varying  in  size  from  a  goose-quill  to  a  broad  band,  according  to  the 
extent  of  the  surrounding  inflammation,  sometimes  marked  upon  the  sur- 
face by  a  red  line.  This  hard  cord  may  extend  from  the  chancroid  a  cer- 
tain distance,  or  may  be  traced  to  the  root  of  the  penis.  Sometimes  it  is 
found  only  toward  the  root  of  the  penis,  being  absent  in  front.  If  the 
superficial  lymphatics  are  also  involved,  the  skin  may  become  oedematous, 
erysipelatous,  hot,  and  tender.  If  the  hard  cords  are  sufficiently  tender, 
erection  puts  them  upon  the  stretch  and  causes  pain.  If  the  inflammatory 
symptoms  run  high,  there  is  a  corresponding  amount  of  general  reaction 
in  the  way  of  fever,  etc. 

The  terminations  of  inflammatory  lymphangitis  are  by  resolution  and 
suppuration.  The  pus  of  the  latter  is  always  simple,  non-virulent,  and  is 
due  to  excess  of  inflammatory  action.  The  little  abscess  generally  heals 
promptly,  and  the  lymphangitis  always  gets  well. 

Virulent  lymphangitis  is  very  rare.  It  possesses  all  the  foregoing 
mptoms  in  a  high  degree,  and  goes  on  promptly  and  necessarily  to  sup- 
puration at  one  or  more  of  the  knotty  points  along  the  inflamed  cord. 

e  pus  discharged  is  auto-inoculable,  and  yields  chancroid.     The  ab- 


CHANCROID.  45 

scesses  at  the  suppurating  points  do  not  heal,  but  become  chancroids,  and 
require  to  be  treated  as  chancroids. 

Treatment. — Mild  cases  require  no  special  care.  If  pain  and  surface 
redness  run  high,  a  cool,  evaporating  lotion  (p.  38)  is  appropriate,  the 
patient  remaining  in  bed  with  the  penis  elevated,  and  not  hanging  down 
between  the  thighs.  Poultices  are  objectionable,  since  they  soften  the 
epidermis,  and  tend  to  increase  the  size  of  the  resulting  chancroid,  should 
suppuration  ensue  and  prove  virulent.  Abscesses  should  be  opened 
promptly,  and  dressed  dry  with  absorbent  cotton,  frequently  changed. 
They  get  well  shortly  if  the  suppuration  be  innocent;  if  virulent,  they  are 
chancroids,  and  must  be  treated  as  such. 


THE    BUBO    OF    CHANCROID. 

The  term  bubo  is  no  longer  confined  to  inguinal  swellings,  but  is  ap- 
plied indifferently  to  the  enlargement  of  any  lymphatic  gland  in  the  body 
when  the  immediate  cause  is  a  recent  venereal  ulcer,  chancroidal  or  syphi- 
litic. 

All  authors  and  statisticians  agree  that  bubo  occurs  with  chancroid, 
not  oftener  than  once  in  three  cases.  It  is  more  common  in  men  than  in 
women,  and  the  strumous  and  lymphatic  are  especially  prone  to  it.  The 
inflammation  is  confined  to  the  ganglia  of  the  superficial  chain,  the  deep 
glands  always  escape,  the  glands  nearest  the  ulcer  are  most  often  involved. 
There  are  two  varieties  of  bubo:  the  simple,  and  the  virulent.  No  statis- 
tics show  their  relative  frequency;  but  it  is  probable  that,  if  only  those 
buboes  which  actually  suppurate  are  considered,  the  number  of  virulent 
buboes  will  be  found  fully  as  great  as  that  of  the  simple  suppurating 
variety. 

Bubo  usually  occurs  in  the  groin  corresponding  to  the  side  of  the  penis 
involved  by  the  chancroid  ;  but  it  may  be  in  the  other  groin,  when  it  is 
called  a  crossed  bubo;  or  double  bubo  may  occur  with  a  single  sore.  Only 
one  group  of  glands  is  involved  in  suppuration. 

Bubo  is  sometimes  peri-glandular,  the  gland  itself  escaping.  When  a 
chancroid  inflames,  simple  bubo  is  a  little  more  apt  to  occur  than  with  the 
typical  uninflamed  sore. 

Simple  bubo. — This  is  the  so-called  sympathetic  bubo.  It  is  due  to 
the  presence  of  irritation  along  the  line  of  the  lymphatic  radicals  belong- 
ing to  the  gland  involved.  Simple  bubo  may  occur  spontaneously  from  a 
strain,  or  without  known  exciting  cause,  in  a  lymphatic  person.  It  is 
found  sometimes  complicating  gonorrhoea,  or  attending  ulcerated  herpes. 
It  may  even  occur  in  connection  with  an  irritated  syphilitic  chancre.  Any 
sore  of  any  character  may  give,  rise  to  it  in  a  subject  who  is  predisposed, 
especially  if  he  be  run  down  physically  at  the  time;  but  chancroid  is  the 
most  common  cause. 

Simple  bubo  generally  occurs  early,  if  at  all,  commencing  within  a  week 
or  two  after  the  chancroid  is  fairly  under  way;  yet,  it  may  occur  when 
the  ulcer  has  nearly  run  its  course.  The  immediate  determining  causes 
are  often  fatigue,  excess,  mechanical  injury  to  the  gland  ;  but  chancroid 
alone  may  cause  it  without  the  assistance  of  any  of  these  additional  prov- 
ocations. 

Generally,  only  one  gland  is  affected,  or  one  gland  so  much  more  promi- 
nently than  the  others  that  the  latter  may  be  disregarded.  Exception' 
ally,  several  glands  suppurate. 


46  THE   VENEREAL   DISEASES. 

The  symptoms  of  simple  inflammation  of  a  lymphatic  gland  are  at  first 
a  sense  of  stiffness  in  the  groin  and  a  slight  swelling  of  a  single  gland. 
The  gland  rolls  under  the  skin,  is  sensitive  to  pressure,  and  the  seat  of 
pain  upon  standing,  walking,  and  particularly  upon  going  upstairs.  As 
the  gland  increases  in  size,  the  pain  proportionately  increases.  The  skin 
finally  adheres  and  becomes  reddened.  Then  it  becomes  redematous,  and 
a  central  soft  spot  appears,  indicating  suppuration.  Occasionally  the 
peri-glandular  tissue  suppurates,  the  gland  itself  undergoing  resolution. 
Left  to  itself,  the  abscess  opens,  discharges  for  a  varying  period,  accord- 
ing to  the  general  condition  of  the  patient  and  the  amount  of  rest  he 
allows  the  sore.  Much  exercise  always  interferes  with  rapid  repair,  on 
account  of  the  position  of  the  ulcer.  Occasionally  the  pus  burrows  in 
various  directions  beneath  the  skin. 

This  is  the  typical  inflammatory  bubo.  Its  course  may  be  arrested 
spontaneously,  or  by  treatment  at  any  period,  even  after  suppuration  has 
been  established.  Simple  pus  in  a  bubo  may  be  absorbed.  The  amount 
of  fever  or  general  systemic  disturbance  is  considerable  in  some  cases,  ab- 
sent in  others.  Suppuration  may  be  announced  by  chill.  Finally,  simple 
bubo  may  be  complicated  by  gangrene  or  by  erysipelas,  but,  apparently, 
not  by  phagedaena. 

Indolent  bubo  is  a  sub-variety  of  simple  bubo.  Patients  with  this 
form  of  bubo  are  generally  lymphatic  or  strumous  in  constitution.  The 
bubo  is  often  double,  a  number  of  lymphatic  glands  being  involved  on 
each  side.  These  glands  grow  rather  slowly,  and  become  matted  together 
by  inflammatory  changes  in  the  surrounding  atmosphere  of  connective 
tissue.  The  compound  tumor  may  reach  the  size  of  an  egg  or  a  small 
orange,  be  attended  by  but  little  pain,  and  perhaps  no  appreciable  systemic 
disturbance.  The  adherent  integument  over  the  lump  is  thin,  livid,  some- 
times shining,  usually  of  a  dead  hue,  sometimes  smooth,  sometimes  cedema- 
tous  and  lying  in  welts  over  the  glands  along  the  folds  of  the  groin.  The 
pressure  of  the  tumors  may  so  interfere  with  the  return  circulation  from 
the  penis  and  scrotum  that  the  latter  become  enormously  cedematous  in  a 
passive  way.  Generally  the  penis  and  scrotum  are  not  altered. 

This  livid,  chronic  enlargement  in  the  groin  may  continue  for  weeks, 
possibly  for  months  unchanged,  occasioning  very  little  annoyance.  Some- 
times, on  the  other  hand,  it  is  attended  by  considerable  pain.  The  chan- 
croid may  have  healed  up  long  before  any  change  has  occurred  in  the 
buboes — sometimes  even  before  they  have  reached  their  full  development. 

The  course  of  indolent  bubo  is  variable.  Sometimes  it  undergoes 
gradual  resolution  without  any  breakage  of  the  skin,  occasionally  after 
small  foci  of  suppuration  beneath  the  skin  have  given  evidence  of  their 
existence  by  fluctuation.  Generally,  peri-glandular  suppuration  occurs, 
and  one  or  more  small  perforations  of  the. thinned  and  livid  integument 
occur,  allowing  exit  to  a  small  amount  of  sanious  watery  fluid  containing 
a  few  pus-corpuscles.  Discharge  from  these  openings  continues,  but  the 
glands  do  not  break  down.  The  pus  burrows  in  different  directions  slowly 
under  the  skin,  and  at  the  bottom  of  long  sinuses  other  little  livid  ab- 
scesses may  form  and  open  spontaneously,  leaving  rigid  fistulae  to  dis- 
;harge  interminably.  The  openings  in  the"  skin  may  enlarge,  and  a  gland 
covered  with  pale,  unhealthy  granulations  protrude. 

This  condition  of  things  may  last  for  months,  even  years.     The  pus  of 

ich  a  bubo  is  never  auto-inoculable  if  the  patient  be  even  reasonably 

The  indolent  bubo  may  occur  independently  of  chancroid  in  all 

espects,  and  follow  the  above  detailed  course  accurately.     There  is  an 


CHANCROID.  47 

indolent  bubo  of  syphilis  similar,  in  many  respects,  to  the  one  just  de- 
scribed, excepting  that  it  does  not  often  suppurate.  Treatment  of  indolent 
bubo,  p.  49.) 

The  spontaneous  bubo  or  bubo  without  a  sore,  is  a  simple  bubo 
arising  from  a  strain,  fatigue,  struma,  cachexia,  local  injury.  It  has 
nothing  to  do  with  syphilis,  and  no  connection  with  chancroid,  and  does 
not  imply  either  of  the  latter  diseases  any  more  than  does  a  suppurating 
gland  in  the  neck.  Much  was  formerly  written  of  this  bubon  d'JEmblee, 
especially  as  a  supposed  evidence  of  the  existence  of  syphilis  without  a 
sore. 

Less  will  be  heard  of  it  in  the  future.  Its  claims  to  recognition  as  a 
venereal  malady  have  been  entirely  overthrown,  and  its  accidental  posi- 
tion in  the  groin  alone  gives  it  interest  and  respectability,  more  than  at- 
taches to  the  same  identical  lesion  when  it  occurs  spontaneously  in  the 
axilla. 

A  form  of  spontaneous  bubo  has  been  described  furnishing  auto-inoc- 
ulable  pus,  and  not  accompanying  a  chancroid.  Such  a  bubo  must  exist 
upon  a  cachectic  or  syphilitic  person,  whose  skin  may  be  induced  to  ul- 
cerate by  the  application  of  non-virulent  pus — or  a  chancroid  must  have 
existed,  as  a  cause,  and  have  cicatrized,  or  have  been  overlooked.  It  may 
have  been  in  the  rectum  and  not  have  been  sought  after  at  all.  In  any 
•case  the  bubon  d'Emblee  of  the  present  day  is  not  considered  to  be  either 
chancroidal  or  syphilitic.  It  is  a  spontaneous,  simple,  inflammatory  bubo. 

Treatment  of  simple  bubo. — Simple  bubo  may  often  be  aborted. 
The  moment  a  trifling  stiffness  in  the  groin  begins  to  be  felt,  and  a  single 
gland  is  found,  by  pressure,  to  be  the  sensitive  spot,  the  greatest  amount 
-of  rest  possible  should  be  insisted  upon.  Rest  in  bed  is  most  desirable, 
but  patients  will  rarely  consent  to  it.  In  any  case  the  patient  should 
keep  off  his  feet  as  much  as  possible.  The  diet  should  be  moderated  in 
conformity  to  the  rest  enjoined,  not  for  any  so-called  antiphlogistic  rea- 
son. Stimulants  should  be  avoided.  A  laxative  may  be  required.  The 
chancroid  should  be  cauterized  at  once,  if  it  is  a  sore  suitable  for  that 
treatment.  In  this  way  its  poisonous  quality  is  best  allayed,  and  the 
bubo  perhaps  saved  from  becoming  virulent. 

If  the  patient  is  full-blooded,  a  dose  of  bitter  water  or  of  salts,1  every 
morning,  will  probably  serve  as  well  as  leeches — the  objection  to  the  lat- 
ter being  that  their  bites  sometimes  fail  to  heal,  and  all  become  inoculated 
should  the  bubo  prove  virulent.  The  same  objection  must  be  urged 
-against  all  the  strong  counter-irritants  and  vesicants  used  to  abort  bubo. 
They  are  not  of  service  unless  they  take  off  the  cuticle.  If  they  do  this, 
and  the  bubo,  proving  virulent,  suppurates  promptly,  the  resulting  chan- 
croid is  much  larger  than  it  need  be.  The  risk  of  this  is  not  counter-bal- 
anced by  any  material  gain  likely  to  be  derived  from  the  treatment.  Only 
simple  buboes  can  be  aborted  by  these  means,  which  are  not  uniformly 
successful;  and  simpler  means,  not  at  all  dangerous,  will  often  answer  as 
well. 

Iodine  does  not  seem  to  me  to  possess  any  value  in  aborting  simple 
bubo,  and  all  ointments  which  have  to  be  rubbed  in  with  the  fingers  lead 
to  as  much  harm  by  mechanical  irritation  as  they  do  good  by  virtue  of  the 
medicament  they  contain.  I  am  confident  that  I  have  seen  great  good 

1  Keeping  the  patient  nauseated  with  tartar  emetic  for  twenty-four  hours  has  not 
proved  valuable  in  my  hands,  nor  the  expedient  of  gr.  -,X0-  sulphide  of  calcium,  hourly, 
-although  I  have  as  yet  had  but  little  experience  with  the  latter  remedy. 


48  THE    VENEREAL    DISEASES. 

follow  the  application  of  the  following  lotion  to  the  skin  over  the  gland,, 
several  times  a  day,  with  a  camel's  hair  brush  : 


.  Tr.  aconiti  rad., 

Tr.  belladonna;,  aa 
M. 


If  the  skin  be  tender,  so  as  to  experience  any  irritation  from  this  ap- 
plication, the  lotion  may  be  diluted  with  water.  It  is  not  desirable  to 
irritate  the  skin.  Cold  applications  I  have  not  found  to  be  trustworthy, 
and  heat  is  not  desirable  at  the  very  first, 

Should  the  bubo  fail  to  abort  and  go  on  to  suppuration,  it  is  not 
necessary  in  all  cases  to  open  it.  The  popular  idea  that  it  is  harmful  to 
put  back  (z.  c.,  prevent  suppuration  in)  a  bubo  is  entirely  without  foun- 
dation in  fact.  If  the  bubo  has  slowly  and  deliberately  advanced,  it 
cannot  be  virulent,  and  the  pus  it  contains  may  be  absorbed  in  some  in- 
stances. The  proper  treatment  in  most  cases  is  rest  and  slight  pressure 
constantly  applied  to  the  gland,  with  the  use  of  iodine  locally,  which, 
under  these  circumstances,  is  of  value.  The  pure  tincture  of  iodine 
should  not  be  used  ;  it  hardens  and  dries  up  the  skin,  and  causes  irrita- 
tion. Further  absorption  of  iodine  is  also  impossible  after  the  first  few 
applications,  which  make  out  of  the  epidermis  a  barrier  against  absorp- 
tion as  absolute  as  the  shoe  does  for  the  foot.  The  compound  tincture 
diluted  with  an  equal  quantity  of  water,  and  kept  applied  sufficiently 
often  to  keep  up  a  slight  yellow  color  of  the  surface,  is  all  that  is  neces- 
sary. 

If  the  little  abscess  makes  the  skin  tense,  and  its  history  proves  it  not 
to  be  virulent,  it  may  be  evacuated  by  aspiration,  with  a  fine  aspiration- 
needle  introduced  through  the  healthy  skin  near  the  point  of  suppura- 
tion, and  thrust  obliquely  into  the  cavity  of  the  abscess. 

By  these  means,  with  good  food,  cod-liver  oil,  and  tonics,  a  bubo 
which  has  suppurated  may  sometimes  be  discussed  without  leaving  a 
scar.  The  reddened  skin  grows  pale,  the  tense  shining  surface  flattens 
and  scales  off,  the  watery  parts  of  the  pus  are  absorbed  into  the  circula- 
tion, then  the  solid  parts  undergo  fatty  metamorphosis,  become  disinte- 
grated, and  are  slowly  taken  up  by  the  circulation  and  disposed  of. 

When  an  abscess  of  a  gland  forms  rather  promptly  in  spite  of  efforts 
to  arrest  it,  when  the  collection  of  pus  is  large,  when  the  patient  desires 
to  save  time  by  encouraging  suppuration,  a  poultice  of  equal  parts  of 
ground  flaxseed  and  elm  bark,  put  on  hot  and  frequently  changed,  is  the 
best  local  application.  As  soon  as  the  skin  has  adhered  all  around,  and 
a  central  soft  spot  of  fluctuation  can  be  detected,  it  is  proper  to  open  the 
abscess.  No  harm  is  done  if  it  is  opened  too  soon,  and  great  mischief 
may  result  if  the  opening  is  too  long  delayed,  and  the  bubo  should  finally 
prove  virulent.  In  case  of  doubt  whether  pus  has  formed  or  not,  a  large 
needle  (2  Dieulafoi)  upon  a  subcutaneous  injection  syringe,  acting  as  an 
exploring  needle,  will  solve  the  doubt.  In  all  cases  where  any  shade  of 
ioubt  exists  that  the  bubo  may  possibly  be  virulent,  no  time  should  be 
lost,  and  an  opening  is  to  be  made  on  the  first  evidence  of  suppuration. 

To  open  a  bubo  a  few  precautions  must  be  observed.     After  re- 

moving the  poultice,  washing  and  drying  the  parts,  all  the  hairs  likely  to 

terfere  with  the  dressing  should  be  cut  short.     A  curved,  sharp-pointed 

stoury  is  passed  into  the  cavity  of  the  abscess  at  its  highest  or  lowest 

part.     Once  in  the  cavity,  the  point  is  made  promptly  to  follow  the  long 


CHANCKOID.  49 

axis  of  the  cavity  wherever  that  may  lead,  and  is  brought  out  through 
the  skin  at  this  point.  Then,  by  a  sliding  motion,  the  bistoury  incises 
the  skin  between  the  points  of  entrance  and  exit,  and  the  greatest  possi- 
ble length  of  incision  which  the  length  of  the  cavity  of  the  abscess  will 
allow,  is  thus  attained.  There  is  no  possible  advantage  in  a  small  in- 
cision. The  object  is  to  obtain  a  free  exit  for  the  pus,  which  may  be 
virulent.  Haemorrhage  is  not  to  be  feared  from  a  simple  incision  of  the 
skin;  it  will  certainly  heal  as  soon  as  the  cavity  of  the  abscess  fills. 
The  trouble  with  incisions  generally  is  that  they  are  too  short,  and  have 
to  be  kept  open  by  a  variety  of  means,  after  a  while,  in  order  to  allow 
the  cavity  of  the  abscess  time  to  fill  up.  The  long  axis  of  the  cavity  of 
the  abscess  is  the  best  guide  for  the  direction  of  the  incision,  starting,  of 
course,  at  the  most  dependent  part  of  the  cavity  of  the  abscess,  or  at  its 
highest  point.  The  direction  of  the  cut  is  generally  along  the  fold  of  the 
groin;  but  this  is  a  matter  of  no  importance,  except  in  people  who  are 
very  fat — and  these  are  less  likely  to  have  suppurating  buboes  than 
others. 

If  exposure  of  the  cut  edge  of  the  skin  to  the  air  for  a  few  moments 
does  not  arrest  haemorrhage,  the  oozing  surfaces  may  be  touched  with 
the  liquid  subsulphate  of  iron,  and  any  spirting  point  tied.  The  excess 
of  pus  and  blood  that  wells  through  the  cut  is  washed  away,  the  epider- 
mis of  the  cut  edges  greased  with  vaseline,  and  a  dry  dressing  of  absor- 
bent cotton  at  once  applied.  This  is  to  be  changed  repeatedly  at  first. 
No  exploration  of  the  abscess  is  desirable,  no  pressure  upon  it  allowable, 
until  after  it  has  digested  for  a  day  or  two,  and  disclosed  its  character. 
No  poultice  should  be  used  after  the  incision. 

If  the  diagnosis  of  simple  bubo  has  been  correct,  the  cavity  fills 
promptly,  and,  by  the  aid  of  a  little  balsam  or  indifferent  stimulating 
lotion,  closes  in  a  reasonable  period.  If  the  bubo  has  been  virulent  the 
open  cavity  of  the  abscess  is  a  chancroid,  and  requires  treatment  as  such. 

Treatment  of  indolent  bubo. — Indolent  bubo  cannot  be  put  back 
by  aconite,  or  belladonna,  or  iodine,  at  the  start.  From  the  beginning 
to  the  end  the  best  local  treatment  for  indolent  bubo  is  pressure.  This 
cannot  be  satisfactorily  obtained  except  by  confining  the  patient  more  or 
less.  A  good  method  of  applying  pressure  is  to  put  the  patient  upon 
his  back,  make  a  nest  of  one  or  two  thicknesses  of  woollen  batting  over 
the  lump  in  the  groin,  and  upon  this  place  a  canvas  bag  partly  filled 
with  very  fine  bird-shot,  regulating  the  pressure  by  the  tolerance  of  the 
patient.  Two  or  three  pounds  is  generally  all  that  can  be  comfortably 
borne,  although  the  patient  may  bravely  start  out  with  a  heavier  weight. 
Pressure  by  the  pad  of  a  truss  (Ricord)  is  only  applicable,  if  at  all,  to 
discuss  an  indolent  bubo,  not  to  abort  it. 

Another  excellent  method  of  effecting  pressure  is  to  moisten  one  or 
two  fine  sponges,  and  dry  them  under  heavy  pressure,  so  that  when 
dried  they  are  thin  and  flat.  One  or  more  of  these  is  now  bound  by  a 
spica  bandage  tightly  over  the  indolent  gland,  and  when  the  parts  have 
become  accustomed  to  the  pressure,  the  bandage  and  sponges  are  moist- 
ened with  hot  water.  The  swelling  of  the  sponges  causes  a  great 
amount  of  soft  equable  pressure.  Every  twenty-four  hours  the  sponges 
and  bandages  are  to  be  renewed. 

If  the  patient  cannot  attend  properly  to  pressure,  and  have  it  thor- 
oughly carried  out,  other  expedients  may  be  resorted  to.  Here  the  tinc- 
ture of  iodine  may  be  used  with  advantage,  but  more  by  virtue  of  its 
counter-irritating  properties  than  for  any  special  property  of  the  iodine. 
4 


50  THE   VENEREAL   DISEASES. 

The  surface  should  be  kept  black,  cracked,  and  sore,  new  iodine  being 
applied  when  the  epidermis  scales  off.  Blisters  of  cantharidal  collodion, 
applied  one  after  another,  are  also  of  value,  as  is  punctate  cauterization 
applied  with  Paquelin's  thermo-cautery.  The  platinum  point  is  first 
brought  to  a  white  heat,  kept  at  that  point  of  temperature,  and  rapidly 
touched  upon  the  skin  over  the  tumor,  at  twenty  to  fifty  different  spots, 
according  to  the  size  of  the  lump.  The  application  is  not  very  painful, 
and  a  good  effect  in  a  resolvent  way  is  often  produced  upon  the  indolent 
glands  during  the  formation  and  separation  of  the  minute  sloughs.1 

Should  suppuration  come  on,  it  does  not  call  for  any  modification  in  the 
treatment.  The  suppuration  is  generally  peri-glandular,  and  its  entire 
absorption  may  sometimes  be  brought  about  by  pressure.  Should  the 
abscess  open  spontaneously,  or  be  opened  by  the  surgeon  to  discharge  its 
bloody -look  ing  serum,  the  treatment  by  pressure  may  be  continued  unin- 
terruptedly. 

If  the  knife  be  used,  and  time  be  valuable  to  the  patient,  the  best 
and  most  satisfactory  treatment  of  indolent  bubo,  after  peri-glandular 
suppuration  has  occurred,  is  in  many  cases,  undoubtedly,  extirpation  of 
the  offending  glands.  Ether  should  be  given,  all  pockets  and  sinuses 
laid  freely  open,  and  all  the  diseased  glands  scraped  out  with  the  finger 
or  sharp  spoon;  or,  if  they  are  very  large  and  adherent  below,  transfixed 
with  a  double  ligature  through  the  pedunculated  portion,  which  is  to  be 
securely  tied  before  the  gland  is  cut  away.  All  the  enlarged  glands  being 
removed,  and  haemorrhage  arrested  by  tying  bleeding  points,  or  apply- 
ing subsulphate  of  iron  or  the  Paquelin  cautery,  the  gaping  cavity  is 
stuffed  full  of  oakum  soaked  in  balsam  of  Peru.  Any  stimulating  dress- 
ing may  be  applied  later.  This  treatment  is  generally  more  satisfactory 
than  the  extensive  use  of  caustic  pastes  sometimes  employed  in  these 
cases. 

The  appropriate  internal  remedies  for  indolent  bubo  are  tonics,  gener- 
ous diet,  with  wine  and  cod-liver  oil. 

Virulent  bubo. — The  virulent  bubo  is  a  subcutaneous  chancroid.  It 
is  known  sometimes  as  the  bubo  of  absorption.  Some  of  the  true  chan- 
croidal  virus,  whatever  it  may  be,  has  ascended  the  lymphatic  channels 
and  lodged  in  a  gland.  Here  it  breeds,  promptly  calls  ulcerative  action 
into  play  to  effect  its  own  elimination,  and  immediately  begins  to  work 
its  way  to  the  surface,  where  an  ulcer  finally  appears  as  a  chancroid. 
Therefore  suppuration  is  inevitable. 

A  virulent  bubo  may  arise  from  a  simple,  from  an  inflamed,  or  from  a 
phagedenic  chancroid.  There  is  no  certain  date  of  its  appearance.  It 
may  commence  very  late.  In  Puche's "  well-known  case  it  came  on  three 
years  after  the  appearance  of  a  phagedenic  serpiginous  chancroid.  Occa- 
sionally it  declares  itself  just  as  the  simple  chancroid  from  which  it  arises 
is  getting  well.  It  is  usually  mono-glandular.  Sometimes  double  bubo 
exists  with  a  single  chancroid — on  one  side  a  simple  bubo,  on  the  other 
virulent. 

' Ina  recent  German  journal,  anewmethodof  treatingthese  indolent  glands  is  spoken 

t>y  Jacubowitz.     He  injects  into  them  a  watery  solution  of  the  iodine  of  potassium, 

t  to  thirty.     He  injected  in  one  case,  at  one  sitting,  into  one  gland  as  large  as  a 

'? Kl S*'  XV<  °f  the  iodide  in  1  i-  of  water,  injecting  small  quantities  into  different 

the  gland.     He  repeated  this  injection  during  two  days,  four  times  with  suc- 

*  he  claims.     Multiple  acupuncture  has  also  been  well  spoken  of.     I  have  not 

yet  tned  either  of  these  methods. 

*  Lemons  sur  le  chancre  :  Bicord  (Foumier).     2d  ed.,  1860,  p.  46. 


CHANCROID.  51 

k, 

There  is  no  positive  diagnostic  feature  which  distinguishes  virulent 
from  simple  suppurating  bubo  at  first;  but  the  course  of  the  virulent  bubo 
is  more  active,  more  violent.  Peri-adenitis  with  suppuration  is  quite  apt 
to  occur  about  a  virulent  bubo.  The  pus  formed  outside  the  gland  in 
such  a  case  is  not  virulent  until  poisoned  by  contact  of  the  pus  within 
the  gland.  Ricord's  beautiful  demonstration  of  this  is  well  known.  The 
case  is  one  in  which  a  peri-glandular  abscess  was  opened,  and  its  pus  in- 
oculated with  negative  effect.  At  the  same  time  a  gland  lying  at  the 
bottom  of  the  abscess  was  punctured,  and  a  drop  of  pus  taken  from  its 
centre  was  auto-inoculated  with  positive  result.  What  more  brilliant 
demonstration  can  be  required  of  the  difference  in  acridity  of  simple  pus 
and  the  poisonous  pus  of  chancroid. 

The  first  features  of  virulent  bubo,  then,  are  precisely  those  of  simple 
suppurating  adenitis  accentuated.  As  soon  as  virulent  bubo  is  opened  to 
the  air,  its  true  chancroidal  characters  begin  to  appear.  The  cut  edge  of 
the  skin  becomes  at  once  inoculated,  and  the  whole  cut  border  ulcerates. 
The  opening,  whether  made  by  nature  or  the  knife,  grows  larger  by  be- 
ing eaten  away  by  the  slowly  advancing  ulceration.  The  borders  of  the 
ulcer  get  hard,  livid,  undermined,  while  the  integument  surrounding  the 
edges  of  the  sore  assumes  a  dusky  purple  hue,  perhaps  perforates  in  a 
new  spot,  or  sloughs  away  in  pieces.  The  bottom  of  the  abscess,  now  an 
ulcer,  becomes  irregular,  worm-eaten,  covered  with  a  pultaceous,  adherent 
deposit,  discharging  plentifully  an  ill-conditioned  pus,  inoculable  upon 
the  bearer. 

This  ulcer,  with  its  ragged,  abrupt,  ulcerated,  and  undermined  edges,  its 
uneven,  pultaceous  floor,  and  auto-inoculable  discharge,  is  a  true  chancroid, 
subject  to  all  the  complications  to  which  chancroid  is  liable.  The  pus 
may  burrow  along  the  groin,  down  the  thigh,  or  upon  the  abdomen,  lead- 
ing to  obstinate  sinuses  which  much  prolong  the  duration  of  the  sore. 

Phagedaena,  either  in  the  sloughing  or  in  the  serpiginous  form,  may 
attack  a  chancroidal  bubo.  The  latter  is  more  common,  and  is  usually 
the  orign  of  those  extensive  chancroids  which  last  for  so  many  years. 
One  such  of  fourteen  years'  duration  is  on  record.  The  course  of  serpi- 
ginous chancroid  in  the  groin  is  usually  upward  over  the  abdomen,  where 
it  generally  stops  after  having  occasioned  considerable  destruction  of 
tissue. 

The  tissues  sought  out  for  destruction  by  serpiginous  phagedaena  are 
the  connective  and  cutaneous  layers  down  to  the  deep  fascia.  It  is  a 
very  common  thing  in  a  large  hospital  to  see  a  poor  fellow,  who  has  been 
on  his  back  for  weeks  or  months,  with  a  raw  spot  in  the  groin  and  over 
the  abdomen,  as  large  as  the  hand,  from  the  floor  of  which  several  large, 
raw-looking,  unhealthy  glands  project.  The  glands  have  been  spared  by 
the  phagedenic  action,  which  has  swept  away  everything  else  down  to 
the  deep  fascia. 

If  the  phagedaena  does  not  exhaust  itself  upon  the  abdomen,  it  gener- 
ally turns  downward  after  a  time  and  takes  possession  of  the  thigh.  The 
thorax,  although  not  absolutely  proof  against  phagedaena  (as,  indeed,  even 
the  face  is  not),  yet  is  very  rarely  attacked  by  it.  For  this  reason,  the 
chest-wall  below  the  nipple  is  the  position  generally  selected  for  diagnos- 
tic auto-inoculation  of  phagedenic  sores. 

A  phagedenic  bubo  may  have  originated  from  a  non-phagedenic  chan- 
croid, just  as  a  phagedenic  chancroid  of  the  penis  may  have  a  simple  bubo 
or  no  bubo  at  all.  Other  points  relative  to  phagedaena  may  be  found  upon 
p.  38  et  seq. 


52  THE    VENEREAL   DISEASES. 

Treatment  of  virulent  bubo. — When  it  is  suspected,  from  the  ra- 
pidity of  impending  suppuration,  that  a  given  bubo  is  virulent,  it  is  wiser 
not  to  poultice  it  at  all.  No  external  applications,  no  internal  medication 
is  of  any  value.  Suppuration  need  not  be  encouraged — it  is  certain  to 
come  promptly  enough.  Above  all  things,  no  leeches  or  blisters  should  be 
applied  to  break  the  skin  and  furnish  new  foci  for  inoculation  after  the 
bubo  has  begun  to  discharge.  As  soon  as  even  a  few  drops  of  pus  have 
collected  the  knife  should  be  used,  and  the  suppurating  cavity  laid  freely 
open.  The  peri-glandular  suppuration  being  nearer  the  surface  and  in  less 
dense  tissue,  can  sometimes  be  opened  without  cutting  into  the  gland  at 
all.  When  this  can  be  done,  it  is  very  desirable.  The  gland  surely  will 
open  later;  but  the  point  of  importance  is  the  size  of  the  cavity  outside 
of  the  gland,  which  must  eventually  become  one  vast  chancroid.  The 
sooner  this  outside  cavity  is  opened  to  the  air  the  smaller  it  will  be,  and 
the  longer  it  can  remain  open  without  becoming  poisoned  with  the  dis- 
charges from  the  virulent  gland  the  greater  is  the  chance  that  its  walls 
•will  consolidate  and  extensive  burrowing  be  prevented.  Therefore,  it  is 
wise  to  open  any  bubo,  which  has  rapidly  advanced  to  suppuration,  at  the 
earliest  possible  moment  after  pus  has  formed,  to  cut  through  the  integ- 
ument from  without  inward,  if  there  is  very  little  matter  and  not  a  con- 
siderable cavity  full  of  pus,  and  to  endeavor  to  determine  whether  the 
suppuration  may  not  be  exclusively  peri-glandular.  Should  it  prove  so, 
the  gland  might  be  taken  out  at  once  unopened,  and  there  is  a  possibility 
that  the  abscess  might  remain  simple,  instead  of  becoming  chancroidal. 
If  both  collections  are  opened  together,  however,  or,  what  is  more  custom- 
ary, if  the  outer  abscess  has  already  become  contaminated  by  the  gland- 
ular abscess,  before  either  of  them  have  been  opened,  then  the  abscess  is 
already  a  chancroid  before  it  is  opened,  and  the  passage  of  a  knife  through 
it  does  not  alter  its  character. 

The  line  of  treatment,  now,  is  that  suitable  for  a  large  chancroid. 
Cauterization  is  not  desirable,  cleanliness  is  of  the  first  importance,  iodo- 
form  the  best  remedy.  Any  pouching  of  the  borders  indicating  a  ten- 
dency to  burrow  should  be  counteracted  by  prompt  incision  to  the  bottom 
of  the  pouch.  The  cut  edges  will  become  ulcerated  and  the  chancroid 
enlarged,  but  this  is  preferable  to  the  formation  of  a  sinus.  A  little  ab- 
sorbent cotton  should  lie  constantly  upon  the  ulcer  to  suck  up  the  dis- 
charges as  they  form.  The  general  detail  of  management  is  the  same  as 
that  for  ordinary  chancroid,  p.  41. 

Should  a  virulent  bubo  commence  to  grow  phagedenic  while  under  ob- 
servation, no  time  is  to  be  lost.  The  most  thorough  cauterization  possi- 
ble is  all  that  can  be  done;  and  if  this  is  undertaken  promptly,  and  effi- 
ciently carried  out,  the  new  enemy  may  often  be  destroyed  along  with  the 
old  one.  The  general  and  local  management  of  phagedaena  have  been 
given  on  p,  41  et  seq. 


PART  II. 

CHAPTER   I. 

SYPHILIS. 

General  Considerations  upon  Syphilis. — Definition  of  Syphilis. — Effects  of  Climate  upon 
the  Disease. — Present  Mildness  as  compared  with  former  Virulence. — Outline  of 
the  Course  of  Syphilis. — General  Pathology  of  Syphilis. — General  Description  of 
the  Pathology  of  the  various  Lesions  due  to  Syphilis,  and  the  Lack  of  any  Specific 
Quality  in  the  Elements  constituting  these  various  Lesions. 

Definition. — Syphilis  is  a  specific  disease,  acquired  only  by  inheritance 
or  by  direct  contact  of  a  surface  capable  of  absorption  with  the  poisoned 
secretions  of  a  person  already  diseased.  It  is  characterized  by  periods  of 
eruption  of  varying  severity,  and  periods  of  repose  of  varying  duration. 
The  earlier  symptoms  are  superficial,  the  latest  involve  the  viscera.  No 
organ  in  the  body  is  exempt  from  paying  tribute  to  the  disease;  the  con- 
nective tissue  suffers  most.  Treatment  may  shorten  and  modify  the  dis- 
ease; time  alone  can  wear  it  out.  A  perfect  recovery  is  possible. 

GENERAL   CONSIDERATIONS. 

The  foregoing  definition  simply  touches  upon  the  outskirts  of  syphilis. 
Nothing  can  define  it  short  of  a  detailed  description.  It  is  a  disease  of 
magnificent  exceptions,  full  of  absorbing  interest.  It  resembles  everything, 
and  yet  retains  that  special  type  of  personal  individuality  which  enables 
the  careful  student  to  ferret  out  its  peculiarities  amidst  a  labyrinth  of 
symptoms  due  to  other  causes,  and  triumphantly  to  institute  a  treatment 
which  is  almost  certain  to  lead  to  a  happy  result.  The  origin  of  syphilis 
is  involved  in  impenetrable  darkness.  It  has  been  the  subject  of  learned 
essays,  and  volumes  have  been  written  to  prove  all  manner  of  things  con- 
cerning it.  Captain  Dabry  affirms  that  it  was  well  known  among  the  Chi- 
nese two  thousand  years  before  Christ,  and  many  believe  that  it  has  ex- 
isted in  all  countries  ever  since,  under  a  variety  of  unpronounceable  names; 
that  it  was  known  to  physicians  of  ancient  days,  and  during  the  middle 
ages,  although  its  nature  was  not  then  fully  recognized.  Another  equally 
stalwart  corps  of  controversialists  aver  as  hotly  in  other  learned  essays, 
equally  founded  upon  fact,  that  the  disease  was  brought  from  America 
upon  the  ships  of  Columbus,  and  from  this  origin  spread  like  a  plague 
promptly  through  all  Europe. 

In  a  text-book  proposing  to  deal  with  practical  questions,  much  dis- 


54  THE    VENEREAL   DISEASES. 

cussion  upon  this  point  is  as  unprofitable  as  it  must  be  stale,  for  there  are 
no  new  facts  to  adduce,  only  new  combinations  of  them  to  be  made,  and 
no  adequate  advantage  attaches  to  a  successful  accomplishment  of  the 

task. 

It  is  well,  however,  to  know  that  syphilis  was  not  recognized  as  a  mor- 
bid unity  until  the  end  of  the  fifteenth  century,  at  and  after  the  period  of 
the  siege  of  Naples  (1494-5)  by  Charles  VIII.  That  then,  and  for  a  con- 
siderable time  thereafter,  the  disease  behaved  with  unwonted  virulence, 
attacking  all  classes  of  society,  and  killing  a  large  number  of  its  victims. 
From  that  time  to  the  present  day,  syphilis  has  been  a  subject  of  peculiar 
interest  to  all  classes  of  medical  men.  It  enters  the  domain  of  every  branch 
of  pathology.  A  close  acquaintance  with  it  is  claimed  by  the  physician, 
the  surgeon,  the  specialist,  in  nearly  all  branches.  Miles  of  pages  have 
been  written  about  it,  and  yet  all  is  not  known.  Every  year  adds  to  our 
exact  knowledge,  and  brings  new  symptoms  and  new  growths  of  morbid 
phenomena  into  the  fold  of  syphilis,  which  were  not  there  before.  Nearly 
all  the  important  questions  in  syphilis  are  still  in  dispute  among  high 
authorities :  Is  the  poison  single  or  double — capable  of  producing  only 
one,  or  of  yielding  two  diseases  ?  Is  it  peculiar  to  man,  or  may  animals 
also  be  affected?  What  secretions  will  transmit  the  disease,  and  what 
secretions  are  innocuous  ?  Is  it  curable,  or  not  ?  What  treatment  is  best  ? 
All  these,  and  many  more  important  questions,  are  not  finally  settled  to 
the  satisfaction  of  the  profession  at  large.  The  question  of  syphilis  of  the 
nervous  system  has  been  probably  nearly  solved  of  late  years,  and  the 
lesions  of  inherited  syphilis  are  in  a  fair  way  to  be  clearly  comprehended; 
but  the  whole  question  of  hereditary  transmission  from  the  father  is  in- 
volved in  unspeakable  doubt,  the  facts  on  both  sides  being  nearly  equally 
strong. 

To  the  quack,  syphilis  is  a  glorious  harvest;  to  the  unprofessional  mind, 
a  mysterious  horror  of  nastiness  ;  to  the  medical  student,  a  simple  sequence 
of  chancre,  secondaries,  and  tertiaries,  easily  cured — the  first  and  second 
by  mercury,  the  last  by  "potash,"  as  he  puts  it;  and  to  the  earnest  stu- 
dent, a  mine  of  increasing  interest,  always  yielding  new  treasures  to  hon- 
est toil,  full  of  pleasant  surprises,  comforting  by  the  sense  of  power  a 
knowledge  of  its  truths  conveys,  and  going  far  to  create  in  the  physician 
respect  for  the  art  he  practises  and  a  certain  amount  of  belief  in  the  spe- 
cific action  of  drugs. 

Syphilis  is  encountered  everywhere — in  the  palace  of  the  mighty,  in  the 
hovel  of  the  slave.  It  infects  the  infant  before  its  first  breath,  and  attends 
the  gray  hairs  of  age  tottering  to  the  tomb.  The  point  of  entrance  of  the 
poison  may  not  be  found,  need  not  be  sought  generally,  and  no  amount 
of  respectability  can  be  a  guarantee  that  any  given  individual  may  not 
have  encountered  one  of  the  protean  forms  of  approach  -which  this  mon- 
ster is  capable  of  assuming. 

Whatever  and  wherever  was  the  first  origin  of  syphilis  matters  little; 
now  it  is  everywhere,  and  probably  spreading.  All  countries  on  the  globe 
possess  it.  Iceland  and  Africa  are  said  to  suffer  least ;  but,  whatever  im- 
munity the  African  may  enjoy  at  home,  he  loses  by  transplantation,  for 
all  the  worst  forms  of  syphilis  are  seen  in  the  negro  in  this  country. 

In  certain  parts  of  the  world  syphilis  is  said  to  be  exceptionally  mild, 

s  m  Portugal.     H.  Lee  quotes  Ferguson  as  ascribing  this  to  the  fact  that 

the  population  are  saturated  with  syphilis,  and  owe  their  immunity  to  the 

they  are  for  the  most  part  derived  from  syphilitic  parents.     Lee 

relieves  also  that  the  lower  classes  in  other  countries  are  in  a  measure  pro- 


SYPHILIS.  55 

tected  from  severe  syphilis  in  the  same  way,  and  that  the  children  of 
syphilitic  parents  who  themselves  have  inherited  no  disease,  have  yet  de- 
rived from  their  parents  a  measurable  protection  from  severe  attacks  of 
syphilis.  In  certain  countries,  on  the  other  hand,  syphilis  is  said  to  be 
exceptionally  malignant — South  Sea  Islands,  Mexico.  The  acquisition 
of  syphilis  by  one  race  of  people  from  another  is  believed  to  produce  a 
severe  type  of  disease.  Syphilis  acquired  by  Europeans  from  the  Chinese, 
or  by  residents  ot'  the  United  States  from  Central  or  South  Americans,  is 
said  to  be  unusually  bad  in  its  results.  It  is  well  known  that  sailors  habit- 
ually have  the  disease  severely,  and  they  acquire  it,  doubtless,  often  in 
foreign  ports.  Hirsch  '  has  shown  that  no  necessarily  good  or  bad  influ- 
ence upon  the  evolution  of  syphilis  attaches  to  climate  alone.  In  a  gen- 
eral way  an  equable  climate  is  less  unfavorable  than  an  uneven  one.  A 
person  not  acclimated  is  believed  to  be  more  apt  to  suffer  severely  in  any 
climate  than  a  native,  if  he  gets  his  poison  from  a  native  ;  while,  on  the 
other  hand,  it  has  been  frequently  noticed  that  where  the  disease  is  im- 
ported into  a  country  previously  exempt,  the  inhabitants  fall  beneath  the 
new  malady  as  under  a  plague. 

A  natural  deduction  from  the  foregoing  facts  is,  that  finally  syphilis 
will  become  uniformly  acclimated  all  over  the  world  ;  that  it  will  diminish 
in  severity  as  it  increases  in  extent,  and  perhaps,  at  last,  may  exhaust  its 
virulence  entirely.  Certain  it  is  that  the  syphilis  of  the  present  day  is 
not  the  syphilis  we  read  of  in  the  past.  It  can  be  recognized  as  the  same 
disease  ;  all  the  features  are  there,  but  much  of  the  sting  has  gone  out 
of  it.  Occasional  cases  of  malignant  syphilis  and  bad  types  of  disease 
still  appear  to  remind  us  of  what  the  poison  can  do,  and  the  damaging 
blight  which  the  inherited  taint  often  inflicts  upon  its  innocent  victim 
attests  the  continued  virulence  of  the  malady.  In  a  majority  of  cases, 
however,  in  reasonably  healthy  persons,  the  type  of  the  disease,  as  encoun- 
tered at  the  present  day,  is  mild ;  it  can  be  controlled  to  a  great  extent 
by  treatment ;  thousands  of  individuals  pass  through  it,  unharmed  in  tis- 
sue, in  feature,  in  function,  to  reach  a  green  old  age  and  die  of  natural 
causes,  leaving  behind  them  healthy  offspring,  who  know  not  the  sins  of 
their  fathers. 


OUTLINE    OF   THE    COURSE    OF    SYPHILIS. 

After  contact  of  the  poison  with  a  surface  capable  of  absorption, 
nothing  unusual  happens  for  several  weeks;  this  is  the  period  of  incuba- 
tion, in  which  the  disease,  already  acquired,  is  supposed  to  hatch  or  ripen. 
A  period  of  incubation  is  quite  common  in  contagious  diseases,  especially 
in  those  which  involve  the  blood.  When  poison  is  brought  into  contact 
with  the  tissues,  if  its  effect  is  to  be  local  there  is  no  incubation;  witness 
the  poison  of  the  bee,  of  the  mosquito,  of  chancroid.  If  its  effect  is  to  be 
general,  it  lies  dormant  while  increasing  in  the  blood,  until  finally  it  has 
accumulated  enough  force  to  break  out  and  produce  symptoms;  and  these 
symptoms  may  be  general  from  the  first,  as  in  measles,  scarlet  fever,  small- 
pox; or  a  lesion  may  first  reappear  at  the  point  of  entrance  of  the  poison — 
hydrophobia,  syphilis. 

The  lesion  which  first  appears  at  the  inoculated  point  is  called  a  chan- 
cre, whether  it  appears  upon  the  genitals,  the  fingers,  the  face,  or  else- 

1  Handbuch  der  histor.  geograph.  Pathologic.     Erlangen,  1860. 


56 

where— whether  it  is  a  dry  papule,  a  moist  tubercle,  or  an  excavated  ulcer. 
This  lesion  is  generally  attended  by  a  peculiar  hardness  of  the  tissues  im- 
mediately underlying  it,  known  as  a  specific  induration.  Within  two 
weeks  the  neighboring  lymphatic  glands  generally  become  slightly  en- 
larged and  verv  hard,  in  an  almost  painless  manner,  many  glands  being 
usually  involved  at  the  same  time.  None  of  these  glands  suppurate  as  a 

rule. 

Generally,  in  about  a  month  after  the  glands  enlarge,  after  the  second 
period  of  incubation,  an  eruption  appears  scattered  more  or  less  uniformly 
over  the  whole  body.  These  eruptions,  for  there  are  a  number  of  them 
which  may  appear — pustular,  papular,  erythematous,  squamous,  differing 
in  intensity  in  different  individuals — these  eruptions  are  all  characterized 
by  certain'general  peculiarities,  to  be  detailed  later,  which  stamp  them 
with  an  individuality  found  by  experience  to  belong  to  no  other  group 
of  eruptions.  Their  color  is  peculiar,  their  grouping,  their  course,  the 
absence  of  pain  or  itching,  and  other  features,  generally  make  it  easy  to 
distinguish  these  eruptions  from  others  composed  of  the  same  elementary 
lesions,  but  due  to  a  different  cause. 

Just  before  the  outbreak  of  the  first  of  the  early  eruptions,  some  pa- 
tients (perhaps  one-third)  suffer  from  a  mild  amount  of  fever,  the  temper- 
ature, generally  moderate,  in  exceptional  cases  mounting  quite  high. 
Also,  coincidently  with  the  first  general  eruption,  or  before  it,  there  is  a 
tendency  to  a  slight  general  indolent  engorgement  of  certain  lymphatic 
glands,  notably  the  post-cervical  chain  and  the  epi-trochlear  glands. 
Rheumatoid  pains  are  often  complained  of — worse  at  night.  Sometimes 
there  is  headache,  a  general  fall  of  hair  is  often  noticed  (alopecia),  and 
acute  iritis  may  be  an  attendant  symptom. 

Also,  with  the  first  eruptions,  or  just  before  them,  erythematous 
patches,  erosions,  ulcers,  and  peculiar  lesions  called  mucous  patches,  are 
quite  certain  to  make  their  appearance  within  the  mouth  and  upon  the 
throat  of  the  patient.  Such  erosions,  patches,  and  ulcers  crop  out  from 
time  to  time  throughout  the  entire  course  of  syphilis,  often  continuing  to 
appear  for  many  months  after  all  other  evidences  of  the  disease,  local  and 
general,  have  passed  away. 

Several  outbreaks  upon  the  skin  may  follow  each  other  during  the 
first  year.  In  such  case  the  eruptions  are  generally  slower  in  their  course, 
each  succeeding  one  a  little  slower  than  its  predecessor,  a  little  deeper- 
seated  in  the  integument  and  less  generalized  in  distribution,  more  group- 
ed into  patches. 

The  bodily  health  sometimes  fails  considerably  during  the  first  year, 
but  it  sometimes  remains  seemingly  undisturbed,  more  especially  in  those 
cases  in  which  the  stomach  retains  its  tone  and  the  appetite  continues 
fair. 

At  the  end  of  a  year  or  more  of  such  outbreaks,  there  is  a  natural  lull 

in  the  course  of  the  disease.     There  may  be  an  entire  absence  of  symptoms 

for  many  months.     In  very  exceptional  cases  the  lull  remains  permanent, 

d  the  patient  seems  to  be  and  to  remain  well  from  that  time  on.     Usu- 

lly,  however,  after  a  period  of  quiescence  more  or  less  long,  new  out- 

reaks  appear  upon  the  skin,  in  groups  of  pustules,  scales,  or  papules,  and 

new,  whitened,  excoriated  patches  and  ragged  ulcers  come  out  upon  the 

i  and  in  the  mouth.     Periosteal  pains  in  all  the  superficial  bones  are 

apt  to  make  themselves  felt,  chiefly  at  night,  and  a  certain  amount 

of  failure  m  general  health  is  customary. 

state  of  things  prolongs  itself  for  a  period  varying  from  a  few 


SYPHILIS.  57 

months  to  two  years  or  more,  and  terminates  by  leaving  the  patient  sound 
and  well,  or  by  merging  into  the  next,  the  tertiary  stage.  The  stage  just 
described  is  sometimes  known  as  intermediary;  the  eruptions  occurring 
in  it  often  leave  slight  permanent  scars. 

In  a  typical  case,  after  an  interval,  or,  perhaps,  without  any  halt,  the 
disease  puts  forth  its  last  group  of  symptoms.  These  symptoms  are  ex- 
ceedingly variable  in  intensity  and  extent.  All  the  superficial,  as  well  as 
the  deep  textures  of  the  body,  as  well  as  all  of  the  internal  organs,  may  be 
involved  in  these  lesions.  The  lesions  of  this  stage,  wherever  they  occur, 
are  characterized  by  connective-tissue  hyperplasia,  or  by  gummatous  de- 
posits, and  in  either  case,  by  thickening  of  the  walls  of  arteries  within  the 
pathological  areas.  In  the  skin,  patches  of  tubercles  and  serpiginous  ul- 
cers appear  :  ecthyma  and  rupia,  gummata  of  the  subcutaneous  tissues. 
Nearly  all  the  lesions  of  this  stage  leave  deep  scars.  The  throat  may  be 
attacked  by  rapidly  destructive  gummy  ulceration,  the  bones  of  the  nose 
may  die  and  come  away.  Ulcers  may  develop  upon  the  mucous  membrane 
of  the  stomach  and  intestine,  and  cut  off  nutrition.  The  liver,  the  lungs, 
the  kidneys,  the  heart,  all  have  their  chance  at  suffering  from  tertiary  dis- 
ease, as  indeed  do  all  the  internal  organs  and  tissues.  The  brain  comes 
in  largely  for  a  share  of  notice  when  the  phenomena  of  tertiary  syphilis 
are  mentioned.  Nearly  all  known  chronic  diseases  giving  symptoms 
through  the  brain,  or  through  the  nerves,  may  be  simulated  by  the  symp- 
toms of  tertiary  syphilitic  disease  of  the  brain  and  nerves.  Chorea,  epi- 
lepsy, paraplegia,  hemiplegia,  nearly  all  forms  of  paralysis,  aphasia,  de- 
mentia, insanity,  mania,  and  many  other  maladies  often  owe  their  origin 
to  tertiary  syphilis,  and  are  perfectly  curable  by  a  well-directed  course  of 
anti-syphilitic  medication. 

The  bones,  and  joints,  and  tendons,  and  bursas,  and  muscles,  must  not 
be  forgotten.     They  all  offer  tribute  to  tertiary  syphilitic   disease,  and1 
furnish   appropriate  symptoms,  as  do  indeed  all   the  structures  of   the 
body. 

After  yielding  symptoms  in  the  tertiary  stage,  more  or  less  severe 
in  type,  syphilis  in  course  of  nature  declines,  and  leaves  its  victim  spon- 
taneously. But,  before  this  period  has  arrived,  such  vital  organs  may 
have  become  involved  in  permanent  changes  in  their  structure,  due  to  syphi- 
lis, that  health  is  no  longer  possible,  and  sometimes  life  itself  cannot  be  sus- 
tained. Death,  as  a  direct  result  of  syphilis,  is  uncommon  in  the  adult, 
but  may  be  produced  by  the  occurrence  of  structural  changes  in  the  vital 
organs,  or  by  the  cachexia  of  tertiary  syphilis.  Cachexia  is  one  of  the 
marked  phenomena  of  this  stage,  and  sometimes  seems  to  be  independent 
of  obvious  organic  changes  in  the  tissues. 

This  glimpse  of  the  natural  history  of  syphilis  is  far  from  perfect. 
The  glory  of  syphilis  is  its  irregularity.  No  two  cases  exactly  resemble 
each  other,  and  yet  the  family  likeness  is  quite  strong  in  all.  Whole 
groups  of  customary  symptoms  may  be  omitted  during  the  evolution  of 
the  disease.  Symptoms  may  be  strangely  out  of  place.  Tertiary  gum- 
mata occasionally  appear  a  few  months  after  chancre,  and  symptoms  of 
brain  syphilis  in  the  same  period,  while,  on  the  other  hand,  erythematous 
and  scaly  spots  upon  the  palms,  the  soles,  and  in  the  mouth,  may  crop 
out  long  after  even  the  tertiary  period  seems  to  have  come  to  a  natural 
end. 

Constant  vigilance  on  the  part  of  the  diagnostician  is  called  for  in  the 
investigation  of  many  of  the  desperate  phenomena  of  varioys  chronic  dis- 
eases, to  decide  if  there  be  anything  in  them  suggestive  of  syphilis.  Such 


58  THE    VENEREAL   DISEASES. 

a  cause  is  often  found  when  least  expected,  and  the  reward  amply  repays 
a  careful  search,  for  no  serious  case  is  so  desperate  but  that  the  prognosis 
is  bettered,  if  new  light  can  be  thrown  upon  it  by  ascribing  it  to  syphilis 
as  a  cause.  A  well-directed  treatment  in  such  a  case  will  sometimes  ren- 
der favorable  a  prognosis  which,  without  it,  must  have  been  fatal. 


THE    GENERAL   PATHOLOGY   OF   SYPHILIS. 

The  changes  wrought  by  syphilis  upon  the  organs  and  tissues  of  the 
body  are  very  limited  in  number  and  very  uniform  in  type,  but  the  symp- 
toms to  which  they  give  rise  are  as  varied  as  are  the  functions  of  the  or- 
gans and  tissues  involved.  When  the  poison  is  first  absorbed,  no  one 
knows  what  becomes  of  it.  It  is  probably  increasing  in  quantity  during 
the  period  of  incubation,  and  working  its  way  through  the  lymphatics 
into  the  system.  Some  authorities  believe  that  it  only  grows  locally  dur- 
ing the  first  period  of  incubation.  The  blood  quickly  begins  to  feel  the 
influence  of  the  poison,  and,  as  first  clearly  shown  by  Ricord  and  Grassi, 
to  experience  a  diminution  in  the  bulk  of  its  red  globular  contents,  while 
the  amount  of  albumen  and  of  white  cells  become  increased.  The  latter 
change,  as  Virchow  has  shown,  is  doubtless  due  to  the  fact  that  a  num- 
ber of  the  lymphatic  glands  are  in  a  state  of  irritation  due  to  the  poison. 

Aside  from  these  changes — which  have  in  them  nothing  peculiar  to 
syphilis,  since  they  are  apt  to  be  found  as  well  in  any  other  debilitating 
disease — the  pathological  individuality  of  syphilis  always  shows  itself  in 
all  stages  of  the  disease^  through  the  medium  of  congestion,  of  new  con- 
nective-tissue formation,  or  of  new  cellular  growth,  and  the  three  are  usu- 
ally more  or  less  combined.  They  are  found  in  the  chancre  (page  15), 
they  all  exist  in  the  syphilitic  bubo.  There  is  an  afflux  of  blood  to  the 
part,  the  bundles  of  connective-tissue  fibres  are  thickened  and  condensed, 
and  a  large  number  of  new  cells  are  present.  These  cells  resemble  leuco- 
cytes, the  white  corpuscles  of  the  blood.  According  to  Cohnheim,  they 
are  nothing  else  but  out-wandered  cells,  which  formerly  were  white 
blood-corpuscles;  yet  the  great  pathologist  Virchow  cannot  distinguish 
between  these  white  cells  found  in  the  syphilitic  chancre  and  the  cells 
found  in  a  fresh  gummy  tumor.  Who  then  shall  decide  that  there  is 
anything  specific  microscopically  in  the  character  of  syphilitic  tissue  ?  It 
is  in  the  structure  and  arrangement,  not  in  the  elements  of  syphilitic  new- 
growths,  that  the  microscopist  seeks  to  make  a  distinction  between  them 
and  other  morbid  neoplasms. 

The  roseola  of  syphilis  is  largely  congestive,  and  due  to  vaso-motor 
paresis  in  the  terminal  capillaries  upon  certain  areas  of  skin.  In  the 
papule,  there  is  cellular  infiltration  as  well.  In  the  pustule  and  vesicle, 
the  exudation  of  pus  and  serum  beneath  the  epidermis  has  no  character 
imprinted  upon  it,  by  its  syphilitic  origin,  which  the  microscope  can  de- 
tect, and  so  on  through  the  various  lesions  of  the  skin.  The  later  cuta- 
neous manifestations  are,  as  a  rule,  gummatous.  The  tubercles,  the  ulcers, 
the  gummata  of  the  skin,  are  all  essentially  different  varieties  of  gumma- 
tous infiltration.  They  all  undergo,  in  the  evolution  of  the  lesion,  the 
natural  retrograde,  fatty -granular  metamorphosis  which  is  the  natural 
termination  of  pure  gummatous  products. 

Within  the  body  there  are  three  pathological  types  of  change  due  to 
syphilis:  connective  tissue  hyperplasia,  gummatous"deposit,  arterial  thick- 


SYPHILIS.  59 

en  ing,  and  two  secondary  changes  often  following  prolonged  syphilitic 
disturbance — atheroma  and  amyloid  degeneration. 

The  connective-tissue  hyperplasia  plays  perhaps  the  most  important 
part  of  all.  The  elements  of  all  the  organs  in  the  body  are  separated 
and  held  together,  suspended,  as  it  were,  in  an  atmosphere  of  connective 
tissue.  Even  the  brain  has  its  fine  connective-tissue  parenchyma,  and 
the  substance  of  the  bone  is  none  the  less  a  variety  of  connective  tissue 
because  it  happens  to  be  solidified  with  earthy  salts. 

One  of  the  commonest  expressions  of  visceral  syphilis  is  that  the  con- 
nective-tissue parenchyma  of  a  given  organ  undergoes  hyperplasia.  Its 
elements  increase  in  number,  soft  round  cells  and  spindle-cells  appear, 
while  all  the  meshes  of  the  tissue  become  more  succulent  from  conges- 
tion. This  state  of  things,  however,  does  not  last  long.  The  hypertro- 
phic  process  comes  to  a  stop,  the  blood  recedes  from  the  congested  ves- 
sels, the  succulent  new  tissue  forms  into  fibres  and  contracts;  cirrhosis  is 
the  result.  Fibrous  bands,  with  all  the  retractile  quality  of  cicatricial 
tissue,  now  replace  the  former  delicate  connective-tissue  atmosphere  of  the 
organ  involved.  The  result  is  inevitable.  The  delicate,  essential  compo- 
nent elements  of  the  gland  or  the  organ  which  has  been  the  seat  of  this 
change  become  squeezed,  and  partly  strangulated  by  the  unwonted  pres- 
sure exerted  upon  them  from  all  sides,  and  the  function  of  the  organ 
becomes  thereby  necessarily  impaired. 

But  there  is  nothing  specific  in  this  form  of  connective-tissue  hyper- 
plasia. Other  forms  of  cirrhotic  change  closely  resemble  it  in  all  micro- 
scopic details. 

The  gummy  tumor  (syphiloma  of  Wagner)  is  a  specific  product.  It  is 
not  due  to  any  other  malady  or  to  any  morbid  process  other  than  syphilis; 
but  there  is  nothing  distinctive  about  the  cells  of  a  gumma.  They  are 
nucleated  cells,  as  seen  in  a  young  gumma,  looking  more  or  less  like  white 
blood-cells.  They  lie  very  closely  crowded  together  in  among  the  ele- 
ments of  the  other  tissues,  which  they  push  aside.  A  few  spindle-cells 
are  generally  found  among  the  succulent  round  cells,  showing  the  tendency 
of  the  tissue  to  organize  into  connective  tissue. 

Such  collections  of  cells  may  develop  in  a  connective-tissue  stroma 
anywhere:  in  or  under  the  skin,  under  the  periosteum,  in  the  Haversian 
canals,  in  the  brain,  the  tongue,  the  throat,  the  lungs,  the  liver,  the 
spleen,  the  kidneys,  the  testicle;  in  any  place  where  connective  tissue  and 
blood-vessels  are  found — in  short,  almost  anywhere  in  the  body.  Gum- 
mata  commence  to  form  usually  around  small  blood-vessels  or  in  the  ad- 
ventitia  of  large  ones,  and  are  found  of  minute  size  scattered  along  the 
fibrous  septa  of  an  organ  in  connection  with  more  or  less  general  connec- 
tive-tissue hyperplasia,  or  as  a  single  large  nodule  of  independent  forma- 
tion, seemingly  a  solitary  lesion  amid  surrounding  health. 

The  connective  tissue  around  a  large  gumma  becomes  condensed  and 
thickened  into  a  sort  of  fibrous  envelope  for  the  newly  formed  mass.  Af- 
ter a  time  the  gumma  reaches  the  size  which  it  is  to  attain,  and  then  de- 
generative changes  commence  in  it.  According  to  Rindfleisch,  this  is  a 
mucous  metamorphosis  of  the  cells  of  the  gumma,  commencing  centrally 
in  the  mass.  The  cells  now  disintegrate  and  become  caseous.  Sometimes 
they  are  wholly  absorbed,  the  spot  remaining  as  a  hard  cicatrix.  This 
cicatrix  represents  mainly  the  outside  connective-tissue  thickening  which 
surrounded  the  gumma,  puckered  in  and  occupying  a  depressed  area 
corresponding  to  the  position  and  proportionate  to  the  size  of  the  origi- 
nal lesion.  Fatty  granular  degeneration  and  caseous  transformation  in 


6Q  THE    VENEREAL   DISEASES. 

large  gummata  surrounded  by  a  considerable  cyst-wall  of  condensed  con- 
nective tissue  yield  a  fluid — a  sirupy  or  a  cheesy  mass,  according  to  cir- 
cumstances. This  mass  may  persist  for  a  time,  and  often  to  the  unaided 
eye  much  resembles  pus,  especially  when  seen  in  subcutaneous  gummata. 
These  collections  may  persist  for  a  long  time  in  internal  organs,  not  ne- 
cessarily doing  much  damage.  The  danger  from  a  gumma  is  usually  di- 
rectly in  proportion  to  the  importance  of  its  place  of  development.  A 
small  gumma  compressing  a  large  vessel  will  naturally  cause  more  phys- 
ical disturbance  than  a  larger  gumma  more  safely  situated.  One  of  the 
common  (the  most  common)  conditions  in  which  to  find  an  old  gumma  is 
a  tough,  dirty  white,  or  yellowish  cicatrix  containing  the  atrophied  re- 
mains of  the  tissue  originally  invaded  by  the  gummatous  infiltration,  and 
more  or  less  of  the  unabsorbed  caseous  remains  of  the  gummatous  cells 
themselves. 

Gummata  situated  near  the  surface  generally  tend  to  act  like  abscesses, 
to  soften  centrally  and  then  ulcerate  their  way  to  the  surface,  discharge 
and  eliminate  themselves  in  the  form  of  gummy  ulcers,  and,  unless  they 
become  serpiginous,  slowly  to  cicatrize. 

The  gummatous  material  is  not  then  in  itself  specific,  but  its  peculiar 
quality  is  evident  to  any  one  studying  its  course.  Similar  material  to 
that  constituting  gumma  is  found  in  syphilitic  chancre  and  in  some  of 
the  secondary  lesions;  yet  it  acts  in  a  different  way,  being  absorbed  with- 
out material  destruction  of  tissue,  and  often  without  leaving  any  scar  in 
the  first  instance,  although  not  necessarily  without  scar  in  the  second. 
This  difference  has  been  explained  by  the  hypothesis  that  the  actual 
syphilitic  virus  comes  into  contact  with  the  tissues  directly  at  the  point  of 
chancre,  and  in  the  secondary  stage  through  the  medium  of  the  poisonous 
blood;  that  these  tissues  behave  in  one  way  under  these  circumstances, 
but  in  a  totally  different  way  when  they  undergo  a  specific  reaction  from 
some  incidental  cause,  having  themselves  been  previously  modified  by 
contact  with  a  poison  which  has  now  ceased  to  exist;  for  it  is  well  known 
that  the  blood  in  tertiary  syphilis  is  not  poisonous  directly,  or,  at  least, 
cannot  be  directly  hetero-inoculated  with  a  positive  result.  This  explana- 
tion is  pure  theory,  and  only  explains  what  is  undoubtedly  a  fact  by 
stating  it  in  other  terms. 

Another  pathological  change  produced  by  syphilis  is  a  modification  in 
the  walls  of  the  blood-vessels.  Biesiadecki  found  the  vessels  thickened 
in  the  primary  lesion,  but  it  has  been  since  discovered  that  this  thicken- 
ing is  a  constant  accompaniment  of  all  inflammatory,  especially  chronic 
inflammatory  changes.  Huebner,  in  his  studies  of  brain  syphilis,  claims 
that  a  large  share  of  the  important  pathological  changes  which  occur  in 
that  organ  are  due  primarily  to  changes  in  the  walls  of  the  arteries  of  the 
brain,  commencing  as  an  endo-arteritis,  and  culminating  in  a  thickening 
of  the  wall  of  the  vessel  and  an  obliteration  of  its  calibre.  The  syphilitic 
endo-arterial  changes  occurring  in  the  different  large  arteries  of  the  body, 
unquestionably  in  undergoing  retrogressive  metamorphosis,  lead  directly 
to  atheroma  and  a  weakening  of  the  arterial  wall,  and  this  again  becomes 
a  direct  cause  of  aneurism. 

The  amyloid  changes  so  often  found  after  death  in  liver,  spleen,  and 

idneys,  in  subjects  who  have  long  suffered  from  syphilitic  cachexia,  do 

•t  differ  from  the  amyloid  changes  due  to  other  causes — such  as  pro- 

onged  suppuration.     It  is  only  syphilitic  in  that  it  is  quite  frequently 

encountered  in  connection  with  that  disease. 


CHAPTER  II. 

SYPHILIS. 

The  Poison  of  Syphilis :  is  it  a  Vegetable  Fungus  ? — The  Production  of  Syphilis  in 
Different  Animals. — The  Alleged  Antagonism  between  Syphilis  and  Cancer. — 
Secretions  which  contain  the  Poison  of  Syphilis. — Peculiar  Virulence  of  the  Secre- 
tion of  Mucous  Patches. — Vaccinal  Syphilis. — Pathological  Secretions. — Physiolo- 
gical Secretions. — Infection  by  Milk  ;  by  Semen. — Transmission  of  Syphilis  by  In- 
heritance through  the  Mother  alone  ;  through  the  Father  alone. — Date  at  which  a 
Healthy  Pregnant  Woman  must  get  Syphilis  in  order  to  Poison  her  Child. — Choc 
en-retour. — Transmission  by  Inheritance  to  the  Third  Generation. 

The  poison  of  syphilis. — That  syphilis  is  essentially  a  poison  has 
always  been  conceded;  but  two  points  regarding  it  have  given  rise  to 
much  dispute,  namely:  exactly  what  the  poison  is,  and  exactly  where  it 
resides.  Both  of  these  points  are  still  the  subject  of  earnest  investiga- 
tion, and  much  serious  and  honest  difference  of  opinon  exists  about  them 
among  intelligent  men. 

Humoral  pathologists  had  no  difficulty  with  poisons  in  the  blood.  An 
assumed  condition  of  irregularity  in  the  fluids  of  the  body  was  a  humor, 
and  any  amount  of  theory  could  be  manufactured  to  fit  the  facts  as  they 
appeared.  Pathology  of  the  present  day  is  more  exact,  and  demands 
tangible  evidence  and  proof  of  what  a  virus  is,  or  else  it  confesses  its 
ignorance,  and  simply  retains  the  term  virus  because  that  is  a  familiar 
one,  and  because  there  is  none  better  at  hand.  An  assumption  of  a  poi- 
sonous quality  in  that  which  is  the  essence  of  syphilis  serves  practically 
to  assist  in  accounting  for  the  phenomena  of  the  disease,  yet  pathology 
does  not  claim  to  know  at  all  what  the  poison  of  syphilis  is.  The  poison 
of  chancroid — most  virulent  in  its  local  effects,  the  poison  of  phagedsena,  of 
measles,  of  scarlet  fever,  of  rabies,  of  erysipelas,  of  septicaemia,  and  many 
others,  none  of  these  are  known  except  by  their  effects.  The  snake-poi- 
son, which  may  easily  be  collected  and  examined,  does  not  disclose  to  the 
microscopist,  or  to  the  chemist,  in  just  what  its  poison  consists.  We 
must,  therefore,  be  satisfied  for  the  present  where  we  are,  and  wait  until 
science  has  advanced  a  step  farther,  and  has  been  able  to  separate  the 
syphilitic  poison  from  the  fluids  which  contain  it,  while  we  still  acknowl- 
edge that  a  poison  does  exist,  because  the  phenomena  of  the  disease  are 
best  accounted  for  upon  that  hypothesis.  As  to  what  the  poison  is,  it  is 
wiser  to  confess  ignorance. 

The  advance  which  modern  investigation  is  making  toward  a  discov- 
ery of  the  exact  cause  of  septic  disease  tends  to  locate  these  poisons  in 
living  germs.  Intimations  have  recently  appeared  in  print  that  a  granu- 
lar substance  has  been  discovered  in  snake-poison,  in  which  presumably 
resides  the  septic  principle.  The  minute,  rounded,  microscopic  bodies 
strongly  refracting  the  light,  which  sink  to  the  bottom  after  a  time  in  a 
tube  containing  pure  vaccine  lymph,  have  been  shown  by  the  investiga- 


62  THE   VENEREAL    DISEASES. 

tions  of  Chauveau  and  Burden  Sanderson  to  be  actually  the  contagious 
element  of  the  lymph.  The  contagious  quality  has  been  shown  not  to 
reside  in  the  liquid  portions  of  the  fluid.  The  strong  advocates  in  mod- 
ern days  of  the  bacterial  origin  of  diphtheria,  erysipelas,  anthrax,  inflam- 
matory changes  in  the  tissues,  show  the  drift  of  scientific  thought;  and 
although,  unfortunately,  the  difference  between  the  bacteria  producing 
diphtheria  and  those  supposed  to  produce  other  diseases  has  not  been 
made  out,  yet  it  is  to  be  hoped  that  closer  investigation  may  eventually 
discover  in  them  distinguishing  traits. 

The  same  efforts  to  discover  a  living  germ  as  the  poison  of  syphilis 
have  been,  and  are  still,  being  made  in  the  profession.  Salisbury  and 
Hallier  both  discovered  a  fungus  which  they  believed  to  be  the  cause  of 
syphilis;  but  other  observers  have  failed  to  accept  their  conclusions,  and 
the  latter  have  gradually  disappeared  from  view.  More  recently  Lostor- 
fer  found  some  little  shining  corpuscles  in  the  blood  of  syphilitic  patients, 
which  seemed  to  behave  in  a  peculiar  manner,  and  immediately  he  an- 
nounced that  the  poison  of  syphilis  had  at  last  been  discovered.  Compe- 
tent observers  promptly  investigated  the  claims  of  the  discoverer,  and  a 
few  months  were  sufficient  to  demonstrate  to  the  satisfaction  of  every 
one  that  the  supposed  syphilitic  corpuscles  were  found  in  normal  blood, 
probably  owing  their  existence  to  the  white  cells  of  the  blood.  Thus 
faded  another  pleasant  delusion. 

Now  another  claimant  is  in  the  field  for  the  honor  of  discovering  the 
germ  which  bears  the  poison  of  syphilis.  Klebs,  a  well-known  and  thor- 
oughly capable  observer,  cultivates  a  spore  which  he  finds  in  syphilitic 
blood  (apparently  a  moving  bacterium),  produces  a  plant,  inoculates  it 
upon  an  ape,  produces  consecutive  ulcers  recalling  the  ulcers  of  syphilis 
clinically  and  histologically,  shows  them  to  Professor  Pick,  who  recog- 
nizes their  resemblance  to  syphilitic  ulcers,  kills  the  animal,  and  finds 
between  the  dura  mater  and  the  skull  a  material  much  resembling  gumma, 
and  a  quantity  of  organic  germs  analogous  to  the  forms  which  had  been 
inoculated  upon  the  animal.  Klebs l  placed  a  portion  of  a  freshly  extir- 
pated syphilitic  chancre  under  the  skin  of  another  ape,  December  29, 
1877.  The  wound  healed  without  suppuration,  the  glands  swelled 
slightly.  In  six  weeks  the  animal  had  fever,  and  shortly  afterward  a  crop 
of  papules  came  out  upon  the  neck,  head,  and  face.  The  papules  were 
flat,  two  or  three  millimetres  in  diameter,  and  of  brownish  red  color. 
These  lesions  scaled  off,  but  did  not  ulcerate,  and  the  papules,  together 
with  the  fever,  disappeared,  leaving  no  trace.  Nothing  new  appeared 
externally,  but  in  five  months  after  the  inoculation  the  strength  of  the 
animal  failed,  and  it  died.  Under  the  site  occupied  by  the  papules 
during  life,  although  no  deeper-seated  disease  had  then  been  detected  at 
these  points,  the  skull  showed  evidences  of  periostitis  and  of  caries  sicca 
— exactly  such  changes  as  are  found  in  man  due  to  syphilis.  A  focus  of 
interstitial  fibrous  thickening  containing  spindle-cells  was  found  in  the 
lung,  the  pleura  being  extensively  thickened  over  it  in  a  radiate  manner. 
Certain  new  formations  of  cells  resembling  young  syphilomata  were 
found  in  the  kidneys.  Finally,  some  blood  taken  from*  this  ape  yielded 
plants  looking  very  much  like  the  fungus  which  had  been  inoculated 
upon  the  first  ape.  The  parasite,  Klebs  says,  consists  at  first  of  movable, 
then  of  stationary  rods,  from  which  latter  grow  spiral  masses  of  linked 

1  Both  cases  are  reported  from  the  proceedings  of  a  meeting  of  naturalists  at 
Cassel,  in  the  Allg.  Wiener  med.  Zeitung,  October  15,  1878,  p.  418. 


SYPHILIS.  63 

rods.  Klebs  calls  the  plants  helikomonads,  does  not  attempt  to  classify 
them  botanically,  and  considers  them  to  be  the  cause  of  syphilis.  A 
number  of  observers  are  doubtless  now  at  work  testing  the  conclusions 
of  Klebs.  It  is  certain  that  their  accuracy  will  be  questioned,  and  more 
than  probable  th,at  the  whole  theory  of  their  causal  relation  to  syphilis 
will  be  overthrown. 

E.  Cutter,  of  Boston,  in  a  lecture  on  the  morphology  of  the  blood, 
delivered  before  the  American  Medical  Association,  January  7,  1878, 
speaks  of  having  found  threads  of  mycelium  and  bacteria  of  a  coppery 
color  in  syphilitic  blood,  and  the  white  blood-cells  full  of  spores,  which 
escape  by  a  rupture  of  the  wall  of  the  cell.  Dr.  Heitzmann,  at  a  recent 
meeting  of  the  New  York  Pathological  Society,  stated  that  he  believed 
he  had  discovered  the  syphilitic  poison  as  it  exists  in  the  blood.  He  de- 
clined to  make  it  known  until  further  study  had  convinced  him  of  the 
accuracy  of  his  facts.  Thus  it  will  be  seen  that  investigation  is  active, 
but  the  problem  is  not  yet  solved. 

Other  animals,  besides  the  apes  of  Klebs,  have  been  successfully  in- 
oculated with  pieces  of  chancre,  or  its  secretion:  guinea-pigs  (Legros, 
Bradley),  monkeys  (Depaul),  cats  (Vernois,  Bradley),  and  ulcers  and 
gummata  produced,  leading  to  marasmus  and  death;  but  the  profession 
has  been  slow  in  accepting  the  evidence  as  demonstrating  syphilis  in 
these  cases.  They  will  be  mentioned  farther  on. 

Thus  far,  then,  no  positive  proof  has  been  adduced  to  show  what  the 
poison  of  syphilis  really  is;  many  more  experiments  must  be  made  before 
the  question  can  be  set  at  rest. 

It  has  been  intimated  strongly  by  Diday  and  Rollet,  that  an  antago- 
nism existed  between  the  poison  of  syphilis  and  the  cancerous  diathesis. 
Inoculations  of  syphilitic  secretions  capable  of  conveying  the  disease 
were  made  by  Rollet,  by  Diday,  and  by  Rodet,  with  negative  result,  upon 
cancerous  patients.  But  this  antagonism  is  certainly  only  apparent.  I 
have  seen  many  cases  in  which  syphilis  and  cancer  existed  clinically  in 
the  same  patient;  and  Hutchinson,  of  London,  at  the  forty-sixth  meeting 
of  the  British  Medical  Association,  went  so  far  as  to  record  his  belief 
that,  while  the  syphilitic  dyscrasia  was  not  a  cause  of  cancer,  yet  the 
prolonged  local  irritation  of  a  syphilitic  sore  might  induce  a  cancerous 
action  in  the  part  involved.  This  assertion,  doubtless,  refers  only  to 
epithelioma. 

The  secretions  -which  contain  the  poison  of  syphilis. — The  uni- 
ty or  duality  of  the  syphilitic  poison  has  been  already  discussed  (p.  7). 
It  remains  to  consider  another  important  question,  namely,  in  what  secre- 
tions does  the  poison  exist  in  such  a  state  that  it  may  be  transmitted  by 
contact. 

The  thin  serous  secretion  of  a  syphilitic  chancre  contains  the  poison 
probably  in  as  concentrated  a  state  as  it  can  be  furnished  by  the  economy. 
The  contagiousness  of  chancre  and  its  clinical  hetero-inoculability  in  kind 
upon  a  virgin  subject  have  never  been  doubted,  since  the  initial  lesion  of 
syphilis  has  been  recognized  as  the  starting-point  of  the  disease.  Con- 
frontations and  direct  experimental  hetero-inoculations  have  proved  this. 

The  authority  of  Hunter,  in  England,  and  the  proclamation  of  Ricord, 
in  Paris,  made  as  late  as  1851,  that  the  poison  of  syphilis  was  transmissi- 
ble only  through  the  secretions  of  the  primary  syphilitic  sore,  and  that 
none  of  the  later  lesions  contained  the  poison  in  their  secretion,  controlled 
the  opinion  of  the  general  profession  for  a  long  time  after  the  assertion 
had  been  clinically  and  experimentally  demonstrated  to  be  an  error. 


64  THE    VENEREAL   DISEASES. 

The  experiments  of  Wallace,  of  Dublin,  in  1835,  amply  demonstrated 
that  inoculation  of  the  secretion  taken  from  ulcerated  mucous  tubercles, 
and  from  the  early  pustular  syphilides,  would  produce  syphilis  in  a  healthy 
subject.  Waller,  of  Prague,  followed  in  1851,  and  since  then  a  great 
number  of  other  investigators  have  been  added  to  the  list,  including  the 
familiar  names  of  Gibert,  LindwQrm,  Barensprung,  and  Hebra,  while  the 
clinical  experience  of  every  physician  who  sees  much  syphilis  constantly 
brings  to  light  cases  where  the  source  of  contagion  has  been,  not  chancre, 
but  the  mucous  patch. 

The  contagious  properties  of  secretions  from  mucous  patches,  and  sec- 
ondary ulcerated  surfaces  upon  mucous  membranes,  have  become  of  late 
years 'so  obvious,  clinically,  that  it  is  questionable  whether  this  lesion  does 
not  divide  the  honors  of  propagating  syphilis  equally  with  chancre,  or  pos- 
sibly even  surpass  its  rival.  Fournier  has  called  attention  to  this  fact, 
and  Biiumler  has  emphasized  it.  Mucous  patches  and  mucous  tubercles, 
ulcers  of  the  mucous  surfaces — all  these  lesions  secrete  freely  and  are  in  a 
position  frequently  to  be  brought  into  contact  with  surfaces  capable  of 
absorption.  The  long  duration  of  these  lesions  makes  them  especially 
dangerous.  They  last  for  months  at  a  time,  and  relapse  frequently  while 
the  syphilitic  chancre,  for  the  most  part,  occurs  upon  a  patient  but  once 
in  a  lifetime,  and  is  of  comparatively  short  duration.  Abrasions  may  be 
inoculated  during  sexual  contact  as  well  from  a  mucous  patch  as  from  a 
chancre. 

Nearly  all  the  examples  of  the  primary  lesion  of  syphilis  encountered 
upon  the  mouth  or  on  the  face,  the  primary  lesion  of  a  suckling  child  de- 
rived from  a  syphilitic  nurse,  of  a  healthy  nurse  from  an  infant  with  in- 
herited disease,  the  cases  of  syphilis  acquired  from  using  spoons,  pipes, 
glass-blowers'  tubes,  those  communicated  by  the  surgeon  through  the  in- 
strumentality of  the  Eustachian  catheter,  the  digital  chancre  of  the  accou- 
cheur— in  all  of  these,  quite  certainly  in  most  instances,  the  vehicle  of  the 
poison  has  been  the  secretion  of  a  mucous  patch. 

Perhaps  the  best  recorded  clinical  evidence  of  the  inoculability  of  mu- 
cous patches  and  ulcers  is  that  furnished  recently  by  the  report  of  Maury 
and  Dulles,1  of  Philadelphia.  James  Kelly,  it  appears,  gained  his  support 
by  walking  through  the  country  and  tattooing,  for  a  small  sum,  all  those 
whom  he  could  induce  to  submit  to  his  mutilation.  Along  his  track  it 
was  found  that  fifteen  individuals  had  acquired  chancre  at  the  tattooed 
points,  with  subsequent  syphilis,  out  of  twenty -two  tattooed.  Kelly  was 
in  the  habit  of  putting  his  needles  into  his  mouth  and  mixing  his  colors 
with  saliva.  On  examination,  Dr.  Maury  found  that  his  mouth  was  full 
of  secondary  syphilitic  lesions. 

Hetero-inoculations  of  syphilitic  blood,  and  of  pieces  of  solid  tissue, 
which  of  course  contain  blood,  have  been  made  experimentally  by  a  num- 
ber of  physicians  (Waller,  the  Anonymous  Surgeon  of  the  Palatinate, 
Pellizzari,  Gibert).  Some  of  the  inoculations  took;  others  yielded  only 
negative  results,  showing  that  the  intensity  of  the  poison  in  blood  is  not 
particularly  great.  Pellizzari  made  five  inoculations,  of  which  only  one 
took.  Among  the  last  three,  which  are  the  most  celebrated,  one  subject 
of  experiment  was  inoculated  with  warm  blood,  with  positive  result;  the 
other  two,  Drs.  Rossi  and  Passigli,  were  inoculated  in  the  same  way,  at 
the  same  time,  but  the  blood  had  become  cold  and  was  coagulated.  The 
result  in  these  two  inoculations  was  negative. 

1  Am.  Journ.  of  Med.  Sciences,  January,  1877,  p.  44. 


SYPHILIS.  65 

Clinically,  cases  are  encountered  where  blood  seems  to  be  the  vehicle 
of  contagion — where,  for  instance,  a  man  acquires  chancre,  and  confronta- 
tion fails  to  detect  any  physical  lesion  in  the  female,  although  perhaps 
here  Morgan's  theory  of  the  contagiousness  of  vaginal  mucus  in  syphilitic 
women  may  explain  the  infection. 

The  secretions  from  pathological  lesions,  not  themselves  syphilitic, 
although  occurring  upon  the  bodies  of  syphilitic  persons,  do  not  contain 
the  virus  of  syphilis,  unless  admixed  with  blood.  Gonorrhoea  upon  a 
syphilitic  patient  reproduces  gonorrhoea  by  inoculation,  and  not  syphilis; 
and  the  same  is  true  of  chancroid. 

Vidal  believes  that  urethritis  upon  a  syphilitic  person  may  produce 
syphilis  by  inoculation.  Hill,  Marsten,  and  Hammond  incline  to  the  same 
opinion.  Tarnowsky,1  in  endeavoring  to  decide  this  point,  made  eighteen 
inoculations  with  blennorrhagic  secretions  from  syphilitic  upon  healthy 
patients,  and  got  one  positive  result.  This  result  goes  to  prove  that  such 
discharges  do  not  contain  the  syphilitic  poison,  for  in  one  case  in  eighteen 
there  surely  might  have  been  an  admixture  of  blood  with  the  inoculated 
secretion.  In  further  explanation  of  the  exceptional  case  may  be  advanced 
the  well-known  fact  that  urethritis  may  come  on  in  a  syphilitic  person, 
due  solely  to  the  development  of  suppurating  mucous  tubercles  within  his 
urethra,  and  these  tubercles  may  yield  a  discharge  which  resembles  that  of 
ordinary  mild  urethritis  (blennorrhagia)  in  all  respects.  Such  discharges 
will  get  well  under  anti-syphilitic  treatment,  as  I  have  had  personal  occa- 
sion to  observe,  and  such  discharges  certainly  must  contain  the  syphilitic 
virus  as  well  as  do  the  discharges  of  mucous  patches  situated  elsewhere. 
If  the  discharges  of  urethritis  are  hetero-inoculable,  producing  syphilis, 
many  wives  would  get  the  disease  who  now  escape,  and  certainly  more 
than  one  out  of  the  eighteen  cases  of  Tarnowsky  ought  to  have  yielded 
a  positive  result.  Without  concluding,  then,  that  such  discharges  cannot 
be  contagious,  it  is  best  to  consider  that  more  proof  is  required  before 
accepting  the  fact  as  demonstrated. 

Duplay's  negative  inoculation  with  pus  from  a  pustule  of  acne  pro- 
duced upon  a  syphilitic  patient,  by  iodide  of  potassium,  is  in  point  here. 

Vaccinal  syphilis  perhaps  yields  the  most  convincing  evidence  that 
heterologous  diseases  upon  a  syphilitic  person  do  not  contain  the  poison 
in  their  secretions.  It  is  well  known  in  all  epidemics  of  vaccinal  syphilis, 
and  there  have  been  many,  that  all  the  children  vaccinated  from  the  vesicle 
upon  the  arm  of  a  syphilitic  child  do  not  become  poisoned,  and,  as  a  rule, 
that  those  first  vaccinated  escape  (receiving  the  serum  only),  while  the 
last  comers  get  also  some  of  the  blood,  and  they  develop  both  vaccinia 
and  chancre  at  the  inoculated  spot.  It  has  been  demonstrated  beyond 
question  that  pure,  clean  vaccine  lymph,  taken  from  a  syphilitic  person, 
is  safe,  and  not  poisoned  with  syphilitic  virus,  so  long  as  admixture  with 
blood  has  been  avoided.  The  vaccine  scab  from  a  syphilitic  person  doubt- 
less could  not  be  used  without  great  danger  of  inoculating  syphilis,  since 
the  scab  always  contains  a  portion  of  the  true  skin  of  the  patient  from 
whom  it  comes.  The  epidemics  of  vaccinal  syphilis  should  teach  the  phy- 
sician never  to  use  lymph  taken  from  a  child  known  or  presumed  to  be 
syphilitic,  for  no  amount  of  care  can  absolutely  guarantee  the  absence  of 
a  trace  of  blood  from  the  vaccine  virus  he  has  gathered. 

Even  at  the  present  day  epidemics  of  vaccinal  syphilis  are  reported, 
and  they  are  likely  to  continue.  So  late  as  Feb.  2,  1878,  there  appeared 

1  Vortrage  iiber  venerische  Krankheiten.     Berlin,  1872. 
5 


6(5  THE   VENEREAL   DISEASES. 

in  the  Italian  Medical  Gazette  of  Lombardy  the  history  of  twenty-six 
children  vaccinated  from  one  syphilitic  vaccinifer,  among  whom  fourteen 
acquired  syphilis.  In  New  York  the  question  of  the  transmission  of 
syphilis  bythe  public  vaccinators  has  several  times  been  before  the  Health 
Board,  and  the  possibility  of  such  an  accident  is  constantly  coming  up  in 
the  minds  of  fathers  of  children  in  private  life. 

Such  experience  as  that  published  by  Jonkoffsky,1  where  fifty-seven 
children  (foundlings)  were  vaccinated  with  lymph  taken  from  eleven  chil- 
dren with  inherited  syphilis,  without  the  transmission  of  syphilis  in  any 
case,  can  be  set  off  by  HutchinsonV  admirable  report,  in  which  ten  out 
of  twelve  vaccinated  got  syphilis,  the  vaccinifer  being  a  seemingly  healthy 
child,  who  afterward  was  discovered  to  have  inherited  disease,  although 
the  mother  seemed  healthy  at  the  time — as  healthy  as  did  the  child. 

Vaccinal  syphilis  frequently  kills  its  victims,  and  there  is  no  possible 
excuse  for  it  in  the  present  day.  Pure  vaccine  virus  can  be  obtained  on 
quill  and  ivory  points,  taken  directly  from  the  calf,  in  most  large  cities  in 
civilized  countries,  capable  of  transportation  for  a  short  distance;  while 
vaccine  lymph,  in  glass  tubes,  may  be  safely  sent  over  the  world  and  re- 
tain its  powers,  as  may  also  the  scabs  from  the  calf. 

It  must  be  remembered  that  vaccination  may  call  out  latent  syphilis, 
and  produce  an  eruption  upon  a  patient  already  syphilitic,  just  as  a  blister 
or  other  traumatism  may  do. 

The  secretions  from  tertiary  lesions  of  syphilis,  serpiginous  ul- 
cers, lesions  of  bone,  etc.,  do  not  seem  to  retain  any  inoculable  quality,  so 
far  as  the  transmission  of  syphilis  is  concerned.  Diday's  sixteen  negative 
inoculations  of  blood,  derived  from  patients  with  tertiary  syphilis,  seem  to 
prove  this,  as  well  as  the  fact  that  a  patient  with  tertiary  lesions  still  upon 
him  may  occasionally  acquire  chancre  anew,  and  run  through  a  second 
mild  course  of  true  syphilis  (p.  83).  The  one  exceptional  case  quoted  by 
Bumstead,  of  the  Ohio  surgeon  who  acquired  syphilis  by  inocxilating  his 
finger  while  operating  upon  syphilitic  disease  of  the  bones  of  the  skull, 
cannot  overthrow  the  rule  without  more  cases  to  confirm  it,  for  there  are 
so  many  accidental  ways  in  which  a  surgeon,  with  an  abrasion  on  his  fin- 
ger, may  acquire  syphilis  in  the  exercise  of  his  profession,  that  the  great 
wonder  is  how  any  person  escapes  who  handles  the  disease  at  all  custom- 
arily. 

Therefore,  with  tertiary  syphilitic  secretions,  as  with  non-syphilitic 
pathological  secretions  upon  syphilitic  persons,  it  is  well  to  reserve  judg- 
ment for  a  time.  They  may  possibly  be  capable  of  carrying  the  poison 
of  syphilis  without  admixture  of  blood;  but  it  has  not  yet  been  proven 
that  they  do  so. 

Of  the  physiological  secretions  it  may  be  quite  confidently  affirmed 
that  none  of  them  are  able  to  communicate  syphilis  by  inoculation.  Mor- 
gan's vaginal  mucus  seems  to  be  an  exception  to  this  rule,  but  it  is  more 
than  probable  that  none  of  the  prostitutes  in  the  Lock  Hospital  had  a 
vagina  so  nearly  healthy  as  to  secrete  only  mucus  ;  the  discharge  in  every 
case  must  have  been  muco-pus,  as,  indeed,  it  was  generally  claimed  to 
have  been.  The  experiments,  moreover,  related  more  to  the  auto-inocu- 
lability  of  these  secretions  than  to  their  poisonous,  syphilitic  character. 

The  tears,  the  urine,  the  saliva,  the  perspiration,  the  milk,  the  semen, 
have  all  been  repeatedly  inoculated  without  success.  Very  recently  a  dis- 

1  St.  Petersbnrger  med.  Zeitachrift,  1872.     I.  p.  73. 

1  London  Lancet,  April  7,  1873,  quoting  Med.  Chir.  Trans.     Vol.  LIV.,  1871. 


SYPHILIS.  67 

cussion  has  been  raised  upon  the  last  two  physiological  secretions,  regard- 
ing their  power  of  transmitting  syphilis. 

Infection  by  milk. — Voss '  reports  a  case  where  the  injection  of  a 
Pravaz  syringeful  of  milk  from  a  syphilitic  woman,  under  the  skin  of  a 
healthy  person,  produced  syphilis  ;  but  his  conclusions  are  arrived  at  with- 
out just  grounds.  The  report  states  that  an  abscess  first  occurred  at  the 
seat  of  the  injection  ;  then,  after  an  incubation  of  forty  days,  a  few  pap- 
ules (the  alleged  chancres)  appeared  around  the  seat  of  the  abscess,  and 
in  five  days  (and  this  is  the  weak  point,  for  no  general  eruption  due  to  a 
chancre  was  ever  known  to  appear  within  five  days  of  the  primary  lesion) 
a  general  maculo-papular  syphilide  came  out. 

A  single  case  can  never  constitute  a  rule  in  syphilis,  for  it  is  almost 
an  impossibility  to  be  certain  to  have  eliminated  all  other  sources  of  con- 
ceivable contagion,  excepting  the  one  under  consideration. 

Milk  from  syphilitic  patients  has  already  been  several  times  injected 
under  the  skin,  with  negative  result  (Padova  and  Profeta). 

Another  case,  published  as  one  of  transmission  of  the  disease  by 
syphilitic  milk,  deserves  notice  here.  Cerasi a  has  reported  that  a  child 
was  given  to  an  apparently  healthy  woman  to  nurse ;  that  the  child  had 
no  chancre  at  the  mouth,  and  that  the  nipple  remained  unbroken  ;  but 
that,  in  three  months,  the  child  became  syphilitic,  quickly  developed  gen- 
eral symptoms,  and  died  in  a  convulsion.  The  autopsy  revealed  gum- 
mata  in  the  brain  and  lungs,  and  an  indurated  liver.  It  now  turned  out 
that  the  nurse  had  had  chancre  two  months  before  assuming  charge  of  the 
child. 

It  seems  paltry  even  to  discuss  such  a  case,  for  the  child  dies  promptly 
with  the  lesions  of  inherited  disease;  the  nurse  has  no  symptoms  except 
headache,  rheumatic  pains,  and  some  pallor  of  complexion,  while  no  rea- 
sons are  given  for  supposing  the  father  and  mother  of  the  child  to  be 
healthy. 

None  of  these  cases,  therefore,  can  count  against  the  investigations  of 
other  competent  observers,  and  milk  must  still  be  considered  incapable  in 
itself  of  transmitting  syphilis,  either  by  inoculation  or  by  ingestion,  and 
must  remain  so  until  incontrovertible  proof  is  adduced  to  the  contrary. 

The  apparent  infections  by  milk  recorded  by  a  number  of  observers 
are  more  than  set  off,  as  the  matter  now  stands,  by  carefully  observed 
cases,  where  children  have  suckled  syphilitic  nurses  and  remained  sound, 
while  inoculations  of  milk  directly  proves  its  lack  of  noxious  quality.  If 
the  nursing  syphilitic  woman  has  a  mucous  patch,  and  the  child  a  fissure 
on  the  lip,  then  the  whole  premises  are  changed,  and  chancre  on  the  lip 
of  the  child  is  the  natural  result. 

Zeissl  believes  that  children  do  become  infected  by  nursing  syphilitic 
women,  whose  nipples  and  lips,  in  consequence  of  a  mercurial  course,  show 
no  signs  of  syphilis  ;  but  he  does  not  state  positively  in  what  manner  he 
believes  the  transmission  of  syphilis  to  occur  in  these  cases. 

The  infectious  quality  of  semen  is  a  matter  of  very  serious  dis- 
pute, both  as  to  its  direct  contagious  properties  and  its  capacity  by  im- 
pregnation to  infect  the  offspring,  the  mother  remaining  healthy. 

On  the  first  point  the  recent  experiments  of  Mireur  3  bear  directly. 

1  Petersb.  med.  Wochenschrift,  No.  23,  1876. 

2  Gaz.  di  Roma,  July,  1877,  and  Jahresbericht  f.  gesammten  Med. ,  Bd.  IL,  Abt. 
II.,  1878.  p.  520. 

3  Annales  de  derm,  et  de  syph.     No.  6,  Tome  VIIL,  1877. 


68  THE   VENEREAL   DISEASES. 

With  true  French  indifference  to  the  means  by  which  he  arrived  at  his 
material  for  experiment,  he  inoculated  four  healthy  individuals  with  semen 
obtained  from  a  man  of  twenty-six  years,  in  fresh  secondary  syphilis,  who 
had  not  received  any  treatment.  The  subjects  of  experiment  were  long 
and  carefully  observed  in  each  c'ase,  with  negative  result. 

Such  positive  proof  of  the  lack  of  contagious  quality  in  the  semen 
more  than  counterbalances  the  claim  of  Von  Barensprung,  that  semen  may 
directly  infect  a  woman,  if  she  conceives  at  the  time  ;  or  of  Porter  and 
Parker,  that  she  may  be  poisoned  through  the  semen  alone,  without  con- 
ception, and  without  the  receipt  of  any  primary  lesion  on  her  part.  The 
small  size  and  ephemeral  character  often  of  the  primary  lesion  in  the  fe- 
male renders  it  necessary  to  accept  the  last  part  of  this  assertion  with 
much  reserve  ;  and  the  evidence  at  best  is  only  negative,  for  a  little  blood 
may  very  easily  escape  from  an  abrasion  in  the  male,  and  carry  the  poi- 
son along  with  the  semen.  On  the  other  hand,  the  mass  of  clinical  evi- 
dence is  enormous,  going  to  show  that  men  in  full  syphilis,  but  without 
local  lesion,  may  have  intercourse  with  impunity,  and  may  even  impreg- 
nate healthy  women,  and  not  transmit  syphilis  to  them  at  all,  or  even  to 
the  offspring.  That  the  semen,  however,  can  transmit  syphilis  by  inheri- 
tance seems  to  be  pretty  conclusively  proved,  as  will  be  related  farther  on, 
but  it  certainly  does  not  always  do  so. 


TRANSMISSION    OF   SYPHILIS    BY   INHERITANCE. 

In  connection  with  the  study  of  the  virus  of  syphilis,  and  of  the  fluids 
which  contain  it  and  may  transmit  it,  the  question  of  transmission  by  in- 
heritance naturally  comes  to  mind,  and  calls  for  consideration  in  this  its 
appropriate  place.  The  question  is  a  knotty  one — and  one,  as  yet,  far 
from  being  solved  to  the  satisfaction  of  the  professional  world. 

In  the  sixteenth  century,  after  syphilis  became  generally  known,  its 
transmission  by  inheritance  was  accepted.  Afterward  it  was  doubted. 
Hunter  doubted  that  syphilis  could  be  inherited.  Ricord  thought  inheri- 
tance was  rather  the  exception  than  the  rule.  During  all  this  time  there 
was  a  general  belief  prevalent  in  the  profession  that  syphilis  could  descend 
to  offspring,  especially  if  the  father  were  diseased  ;  and  finally,  Vassal, 
and  later,  Cullerier,  took  the  other  view,  and  were  the  starting-point  of 
that  opinion  which  to-day  embraces  a  very  large  and  respectable  follow- 
ing, namely:  that  the  father's  disease,  or  health,  is  a  matter  of  no  impor- 
tance, so  far  as  syphilis  in  the  child  is  concerned,  and  that  inherited 
syphilis  cannot  occur,  except  as  a  result  of  constitutional  syphilis  in  the 
mother. 

^  When  both  parents  are  diseased,  the  child  is  quite  certain  to  be  syphi- 
litic, unless  the  poisonous  quality  of  the  malady  in  both  parents,  and  espe- 
cially in  the  mother,  be  pretty  nearly  exhausted.  Cases  have  been  re- 
corded where  the  child  appeared  sound,  in  spite  of  disease  in  both  parents  ; 
and  all  records  dealing  with  this  question  refer  to  cases  in  which,  the 
mother  being  diseased  and  producing  a  number  of  children,  some  of 
these  suffer  but  little,  if  at  all,1  while  others,  born  later,  are  manifestly 
syphilitic.  This  suggests  the  thought  that  during  the  lulls  of  disease, 
when  the  natural  tissues  of  the  mother  seem  to  be  healthy,  perhaps  the 
ovum  may  be  free  from  the  germ  of  the  disease.  It  is  certain  that  a 

1  Mireur,  p.  91. 


SYPHILIS.  69 

syphilitic  woman  under  treatment  may  produce  a  child  in  all  respects 
healthy,  and  then,  giving  up  medicine  under  the  idea  that  she  is  well, 
mav  give  birth  later  to  a  child  about  whose  syphilis  there  can  be  no  doubt. 
One  of  Thurman's  cases,  quoted  by  Mireur,1  is  in  point  here.  Both  parents 
were  syphilitic,  both  had  apparently  recovered  under  treatment,  and  nei- 
ther of  them  showed  any  trace  of  syphilitic  symptoms  afterward,  while 
they  continued  under  Thurman's  observation.  Seven  children  were  born 
to  these  parents  successively,  became  covered  with  syphilitic  eruptions, 
and  died.  In  the  eighth  pregnancy,  the  mother  was  submitted  to  mer- 
cury. A  healthy  child  was  born,  which  remained  well  and  grew  up.  In 
the  ninth  pregnancy,  the  treatment  was  continued,  and  the  child  was  born 
healthy.  In  the  tenth  pregnancy,  supposing  herself  well,  treatment  was 
neglected.  The  child  appeared  well  at  birth,  but  a  syphilitic  eruption 
came  out  later,  and  it  died  in  six  months.  The  mother  finally  became 
pregnant  for  the  eleventh  time.  She  again  received  mercury,  and  her 
child  was  born,  and  continued  healthy. 

That  there  are  some  unexpected  peculiarities  about  the  transmission 
of  syphilis  by  inheritance,  is  certain.  The  theory  that  in  certain  cases 
the  mother,  by  continuing  to  carry  infected  children,  becomes  by  this 
means  herself  constantly  more  and  more  diseased,  cannot  be  supported, 
because  the  examples  proving  it  are  altogether  too  exceptional  to  be  rea- 
soned from.  It  may  seem  to  account  for  the  fact  that  the  older  children 
are  sometimes  more  diseased  than  the  earlier  ones  born  to  the  same  syph- 
ilitic parents  (as  a  matter  of  fact,  this  is  exceptionally  rare) ;  but  the 
rule  remains  that,  in  the  vast  majority  of  instances,  syphilis  exhausts  it- 
self by  lapse  of  time  in  the  mother,  and  her  children  become  less  and  less 
diseased,  and  finally  healthy. 

When  the  woman  alone  is  syphilitic,  the  child  is  quite  certain  to 
inherit  the  disease.  The  ovule  itself  is  a  part  of  the  poisoned  mother,  and 
its  development  into  an  unhealthy  child  is  a  matter  almost  of  necessity. 
Exceptions  to  this  rule  have  been  alluded  to  above,  where  the  mother  has 
syphilis,  then  produces  a  healthy  child,  then  a  syphilitic  one.  Most  of 
these  cases  (Zeissl  has  several  of  them)  can  be  explained  away.  Those 
which  cannot,  must  either  be  accepted  as  a  mystery  yet  unsolved,  or  as- 
cribed to  the  fact  that,  during  a  lull  in  the  disease,  the  impregnated  ovule 
was  and  remained  healthy  throughout.  Adam  Owre,  of  Christiania,  in  a 
number  of  communications  which  have  appeared  of  late  years,  contends 
hotly  for,  and  adduces  numbers  of  cases  in  support  of  Cullerier's  proposi- 
tion, that  syphilis  in  the  child  is  inherited  from  the  mother  alone.  His  last 
report  covers  forty -two  syphilitic  fathers  having  eighty-nine  children.  All 
the  fathers  were  syphilitic,  all  the  children  were  well,  all  the  mothers 
remained  healthy,  all  the  cases  were  observed  in  private  life. 

Sturgis,  of  New  York,  has  stoutly  upheld  this  proposition;  and  J.  W. 
Thompson  says,  in  the  Richmond  and  Louisville  Medical  Journal  for  Feb- 
ruary, 1876,  that  he  has  a  list  of  seventy-two  persons  (adults  and  children) 
who  themselves  are  sound  and  their  mothers  well,  while  he  "  positively  " 
knows  that  all  their  fathers  had  syphilis.  Mireur,  in  his  pamphlet  on  the 
inheritance  of  syphilis,  also  takes  this  view.  Two  of  Mireur's  cases  claim 
rehearsal  here,  for  they  demonstrate  beyond  the  possible  shadow  of  a  doubt 
that  a  syphilitic  father  may  produce  a  healthy  child  if  the  mother  remains 
sound.  One  of  the  cases  (p.  26)  is  this.  C.  has  chancre  and  syphilis. 
In  one  year  he  marries.  In  ten  months  a  healthy  child  is  born,  who  con- 

1  Sur  1'heredite  de  la  syphilis.     Paris,  1867. 


70  THE    VENEREAL   DISEASES. 

tinues  well  up  to  two  years  of  age.  Then  the  child  acquires  a  chancre 
upon  the  lip  from  kissing  its  father,  who  has  at  the  time  an  indolent  ero- 
gion  upon  one  of  his  lips,  and  in  due  time  a  roseola  and  mucous  patches 
at  the  anus  appear  upon  the  child.  In  another  case  equally  instructive,  a 
syphilitic  man  impregnates  his  healthy  wife  and  his  syphilitic  mistress  at 
about  the  same  time;  both  children  come  to  term.  The  one  born  of  the 
healthy  wife  has  no  disease;  the  illegitimate  child,  who  is  said  to  be  the 
image  of  its  father  and  whose  mother  is  also  syphilitic,  is  diseased. 

When  the  father  alone  is  syphilitic,  the  child  unquestionably 
often  escapes  if  the  mother  remains  well.  I  have  the  most  positive  evi- 
dence of  this  in  the  cases  of  seven  young  men  with  twelve  children : 
each  father  had  syphilis,  was  treated  by  me  throughout  the  disease,  got 
married  and  had  children  under  my  observation,  all  in  the  city  of  New 
York.  All  the  children  and  all  the  mothers  are  well.  All  the  young  men 
married  before  their  symptom  had  entirely  disappeared,  all  of  them  have 
had  some  slight  but  positive  symptom  of  syphilis  since  marriage.  Some 
of  the  children  are  under  constant  observation.  All  of  them  are  occasion- 
ally seen.  None  of  them  have  ever  shown  a  sign  of  syphilis.  A  great 
number  of  other  corroborative  cases  are  constantly  turning  up  under  my 
observation,  and  there  can  be  no  reasonable  doubt  of  the  fact  that  a  heal- 
thy woman,  by  a  syphilitic  man,  may  have  a  healthy  child. 

But  that  a  healthy  woman  by  a  syphilitic  man  must  have  a  healthy 
child,  is  altogether  another  question,  and  certainly  is  not  a  fact,  if  there 
is  any  value  in  evidence.  Frankel,1  in  examining  placentae,  found  fourteen 
which  he  believed  to  be  syphilitic,  in  women  who  seemed  healthy.  The 
value  of  this  observation,  however,  is  more  apparent  than  real,  because 
many  pathologists  deny  that  the  so-called  syphilitic  placenta  is  due  to 
syphilis  at  all,  of  necessity. 

Hutchinson  and  von  Rosen  are  inclined  to  ascribe  more  power  to  the 
father  than  to  the  mother,  in  transmitting  syphilis  by  inheritance.  R. 
W.  Taylor,8  of  New  York  (two  cases),  and  J.  N.  Hyde,'  of  Chicago  (three 
cases),  Van  Harlingen,4  of  Philadelphia  (one  case),  have  published  very 
strong  cases  to  show  that  the  father  alone,  if  syphilitic,  can  produce  a 
diseased  child,  the  mother  remaining  sound.  Caspary,  *  Keyfel '  (43 
healthy  mothers,  44  syphilitic  children,  the  fathers  being  syphilitic),  Di- 
day 7  (26  cases),  and  many  others,  have  recently  come  forward  to  sustain 
the  proposition  that  the  father  alone,  without  disease  in  the  mother,  may 
transmit  syphilis  to  the  offspring. 

The  strongest  of  all  the  public  documents  sustaining  this  side  of  the 
question  is  the  recent  monograph  by  Kassowitz,8  wherein  the  whole  sub- 
ject is  submitted  to  an  exhaustive  study  going  to  show,  without  leaving 
room  for  much  doubt,  that  inherited-  syphilis  in  the  child  may  descend  from 
the  father  alone. 

I  have  encountered,  in  what  I  believe  to  be  a  reasonably  large  expe- 
rience, but  one  case  sustaining  this  view,  and  that  one  was  imperfectly 
observed.  The  case  was  that  of  a  child  dying  shortly  after  birth  with 

1  Archiv  f.  Gynaekologie,  1873,  Vol.  V.,  p.  45. 
1  Archives  of  Clinical  Surgery,  September,  1876. 
*  Archives  of  Dermatology,  April,  1878,  p.  103. 
'Ibid.,  April,  1877,  p.  211. 

6  Vierteljahresschrift  f.  Derm  u.Syph.,  4th  Heft,  1875. 
8  Separat  Abdrnck  aus  dem  iirbzl.  Intelligenzbl. ,  No.  21,  1876. 
'  Annales  de  dermatologie  et  de  syphiligraphie,  T.  8,  No.  3,  p.  161. 
Die  Vererbung  der  Syphilis  :  Braumiiller.     Wien,  1876. 


SYPHILIS.  1 

pemphigus  and  cachexia,  where  the  autopsy  showed  syphilitic  lesions  in  the 
lungs,  liver,  and  other  organs.  The  mother  was  apparently,  and  always 
had  been,  healthy,  and  so  did  the  father  appear  to  be;  but  the  latter 
confessed,  after  a  sharp  examination,  that  he  had  had  syphilis  eight  years 
before.  The  mother  was  not  kept  under  observation  long  enough  to  give 
this  case  full  value.  The  mother  was  a  patient  of  Dr.  C.  C.  Lee,  of  New 
York,  who  asked  me  to  see  the  case  with  him. 

It  seems  fair  to  accept  as  proved,  therefore,  that  a  syphilitic  father 
may  procreate  a  syphilitic  child,  and  that,  if  the  mother  at  the  time  of 
conception  is  healthy,  she  may  remain  so,  or  seem  to  remain  so,  indefi- 
nitely, the  child  being  born  syphilitic. 

This  statement  leaves  two  very  weak  points  unsatisfied  by  explanation. 
The  points,  both  negative,  are  these:  in  no  case,  so  far  as  I  remember, 
has  it  been  shown  that  a  healthy  mother,  who  had  produced  a  syphilitic 
child  diseased  from  its  father,  afterward  became  herself  poisoned  by  ex- 
perimental or  accidental  inoculation.  The  other  point  is  this:  Colles's  law, 
so  called,  states  that  a  child  with  inherited  disease  may  poison  a  healthy 
stranger  whom  it  suckles,  by  inoculating  the  breast;  but  that  the  same 
child  cannot  poison  its  mother.  How  this  rule  can  possibly  stand,  unless 
the  mother  is  already  diseased,  it  is  hard  to  conceive.  And  yet  no  au- 
thentic instance  has  been  recorded  in  which,  among  the  great  number  of 
cases  observed,  any  exception  to  Colles's  law  has  been  noted.  Brizio 
Cochi  in  1858,  and  Miiller  in  1861,  are  quoted  by  Kassowitz  as  having 
reported  exceptions  to  this  law;  but  Kassowitz  adds  that  the  cases  were 
not  described  with  great  accuracy  or  distinctness,  and  therefore,  scienti- 
fically, they  are  of  no  value.  Caspary l  attempted  the  only  possible  posi- 
tive solution  to  this  question.  He  found  a  seemingly  healthy  woman  with 
a  syphilitic  husband  and  a  syphilitic  child.  He  inoculated  the  woman 
with  the  secretion  of  syphilis  without  effect,  thus  seeming  to  prove  that 
although  apparently  healthy,  she  already  had  syphilis. 

I  myself  have  one  case  bearing  on  this  point.  A  woman  has  had  un- 
der my  observation  three  children,  all  syphilitic.  Her  husband  was  and  re- 
mains syphilitic.  The  first  child  was  a  few  months  old  when  I  first  saw  it. 
It  was  sent  to  me  for  treatment,  with  the  statement  that  it  had  been  born 
healthy,  had  been  poisoned  by  its  wet-nurse,  and  in  time  had  poisoned  its 
father.  The  child  and  the  father  were  manifestly  syphilitic.  The  mother 
thought  she  was  sound,  and  would  have  passed  for  being  well,  except  for 
a  very  thorough  examination,  which  detected  an  occasional  suspicious- 
looking  macule  upon  the  skin,  and  some  small  but  beautifully  character- 
istic mucous  patches  upon  the  throat  and  inside  the  mouth.  All  three 
were  treated.  The  baby  died.  The  mother  lost  her  symptoms  at  once, 
and  considered  herself  so  well  that  she  refused  treatment;  the  father's 
symptoms  continued  and  were  severe. 

After  a  time  the  wife  again  became  pregnant  in  another  city.  A  child 
was  born  apparently  healthy.  The  mother  was  a  picture  of  perfect  health, 
and  considered  herself  well.  The  father  was  still  under  treatment.  The 
baby  was  pronounced  healthy  by  the  doctor  in  attendance,  and  given  to  a 
wet  nurse.  The  nurse  soon  got  a  sore  on  the  nipple,  then  a  sore  was 
found  on  the  baby's  mouth,  and  both  nurse  and  child  commenced  to  give 
evidences  of  syphilitic  poison  by  eruptions.  On  this  account  the  nurse 
was  accused  of  having  poisoned  the  child  with  syphilis,  and  was  discharged. 
The  child's  mouth  was  treated,  another  nurse  was  sought,  accepted  the 

1  Vrtljhschrift  f.  Derm.  u.  Syph.,  4th  Heft,  1875. 


72  THE   VENEREAL   DISEASES. 

place,  and  after  a  few  weeks  the  family  again  came  to  New  York.  The 
mother  seemed  to  be  in  the  perfection  of  health,  and  no  trace  of  syphilis 
existed  upon  her.  The  child,  now  about  eight  months  old,  looked  like  an 
old  man  ;  the  head  was  small,  the  fontanelle  nearly  closed,  the  body 
wasted,  the  voice  hoarse,  while  a  large  fungating  ulcer  occupied  the  corner 
of  the  mouth.  The  father  had  white  patches  on  the  tongue  and  squa- 
mous,  serpiginous  spots  on  the  scrotum. 

The  new  nurse  was  pale,  had  one  raw,  hard,  beefy-looking  ulcer  on 
the  nipple  and  breast  about  one  inch  long  and  half  an  inch  wide.  She 
was  feverish,  sore  throat  was  commencing,  with  pains  in  the  bones  at 
night. 

Nurse  and  baby  were  put  under  treatment.  The  former  continued  to 
have  a  few  mild  symptoms  of  syphilis  while  under  observation  (six 
months).  The  child's  symptoms  disappeared  under  treatment. 

Finally,  the  mother  became  pregnant  again.  She  seemed  to  be  per- 
fectly well,  but  I  urged  her  to  take  treatment  continuously  through  the 
term  of  utero-gestation.  This  she  failed  to  do  efficiently,  because  she  en- 
joyed, seemingly,  the  absolute  perfection  of  health  and  looked  perfectly 
well.  At  the  end  of  the  eighth  month,  without  cause,  the  child's  move- 
ments in  the  womb  ceased.  At  term,  in  February,  1879,  she  was  delivered 
of  a  dead  child,  the  macerated  condition  of  the  latter  showing  that  it  had 
been  dead  some  time.  In  August,  1879,  I  saw  the  mother  ;  she  had 
taken  no  treatment,  but  showed  no  sign  of  syphilis. 

This  case  is  very  instructive.  Had  I  not  seen  the  mother  before  the 
death  of  her  first  child,  I  should  have  felt  certain  that  she  had  no  syphilis, 
for,  from  that  date  until  this  writing,  now  a  period  of  more  than  three 
years,  she  has  not  shown  the  least  symptom  of  syphilis,  except  by  the 
fact  that  she  has  produced  two  syphilitic  children. 

In  summary  of  the  foregoing  statements,  it  seems  just  to  conclude: 

1.  When  both  parents  are  syphilitic,  the  child  is  almost  necessarily  dis- 
eased.    Exceptions  are  probable  under  treatment  of  the  mother,  or  when 
lapse  of  time  has  exhausted  the  disease  in  the  mother;  exceptions  are 
possible  during  lulls  in  the  disease,  or  under  circumstances  with  which 
science  is  at  present  unfamiliar. 

2.  When  the  mother  is  diseased  and  the  father  healthy,  the  child  is 
syphilitic,  excepting  under  the  same  circumstances  as  obtain  when  both 
parents  are  diseased. 

3.  When  the  father  is  diseased  and  the  mother  healthy,  the  child  is 
healthy,  as  a  rule.     Sometimes  the  child  is  diseased  under  these  circum- 
stances, while  the  mother  seems  to  be  and  continues  to  remain  well  in  all 
respects,  as  testified  to  by  a  number  of  perfectly  competent  observers. 

In  connection  with  this  question  of  the  transmission  of  syphilis  by  in- 
heritance, three  other  points  must  be  considered,  namely:  the  date  at 
which  a  woman,  carrying  a  child,  may  become  syphilitic  without  poison- 
ing the  child;  the  "  choc  en-retour"  of  Ricord;  and  the  transmission  of 
syphilis  to  the  third  generation. 

Date  at  which  a  pregnant  woman  may  become  syphilitic 
without  poisoning  her  child. —Unless  the  mother,  who  has  been 
healthy  and  carries  a  healthy  child,  gets  a  chancre  before  the  seventh 
month  of  pregnancy,  it  is  believed  that  her  child  will  escape  (Ricord, 
Boeck,  Barensprung,  Frankel,  and  others). 

If  the  mother  gets  her  chancre  at  the  moment  of  conception,  or  soon 
after,  she  is  apt  to  miscarry.  If  she  gets  it  later,  the  child  goes  to  term, 
but  is  born  thoroughly  poisoned,  with  poor  chance  of  surviving.  The 


SYPHILIS.  73 

common  agreement  is  that,  if  the  chancre  does  not  appear  before  the 
seventh  month,  the  child  is  safe.  This  is  not  always  the  case,  however,  as 
proved  by  Chabalier's  l  case,  in  which  chancre  did  not  occur  until  the 
ninth  month,  due  to  intercourse  at  the  end  of  the  seventh  month,  with 
thirty-eight  days'  incubation.  In  this  case  the  child  had  syphilis,  of  which 
it  died. 

Choc  en-retour  is  a  fanciful  expression,  meaning  that  a  healthy  wo- 
man conceives  by  a  syphilitic  man,  that  the-ovum  becomes  diseased  through 
impregnation  with  diseased  semen  and  in  its  turn  poisons  the  mother,  the 
latter  never  having  any  chancre,  but  becoming  directly  contaminated  by 
contact  of  her  fluids  with  the  infected  fluids  of  the  fostus. 

The  possibility  of  choc  en-retour  reopens  the  whole  question  of  the 
inheritance  of  syphilis  from  the  father  alone,  already  discussed  above. 
The  possibility  of  this  method  is  seriously  doubted  by  many,  steadfastly 
believed  in  by  others.  It  will  stand  or  fall  upon  a  final  and  definite  solu- 
tion of  the  question  of  inheritance  from  the  father  alone.  If  the  father 
can  transmit  syphilis  to  his  offspring  by  some  quality  his  malady  has  im- 
printed upon  his  spermatozoa — and  there  is  no  reason  to  believe  that  this 
is  absolutely  impossible — then  it  is  very  probable  that  choc  en-retour  ex- 
ists, and  that  the  prolonged  presence  of  the  child  in  utero  necessarily 
poisons  the  mother,  without  chancre,  giving  her  perhaps  a  modified  form 
of  the  disease — not  enough  poison  to  betray  itself  by  the  usual  symptoms 
of  syphilis,  but  enough  to  protect  her  from  acquiring  the  disease  after- 
ward in  a  natural  way,  or  by  inoculation  (Caspary),  and  preventing  her 
child  from  giving  her  chancre  of  the  breast,  thus  justifying  Colles's  law. 

An  occasional  able  essay  upholding  the  possibility  of  choc  en-retour 
appears.  Diday  a  recently  published  such  a  paper,  stating  than  an  ovum, 
or  an  embryo,  or  a  foetus,  poisoned  by  the  father,  might  produce  disease 
in  the  mother  at  any  time  before  birth. 

The  transmission  of  syphilis  to  the  third  generation  has  gener- 
ally been  doubted.  A  common  belief  is,  that  after  syphilis  has  been  once 
transmitted  by  inheritance  it  degenerates  into  something  like  scrofula, 
which  in  its  turn  may  be  transmitted,  although  the  syphilis  may  not.  The 
truth  seems  to  be,  that  the  activity  of  the  syphilitic  poison  is  freshened  up 
by  transmission  to  a  growing  child.  Infection  of  a  healthy  nurse  by  a  dis- 
eased child  is  very  common.  Von  Rinecker  inoculated  a  healthy  physician 
with  pus  taken  from  a  pustule  of  acne  upon  a  child  forty-nine  days  old, 
whose  syphilis  was  inherited.3  Everything  goes  to  show  that  the  poison  in 
a  baby  is  exceedingly  active,  although  that  in  the  parents  may  have  almost 
died  out  before  the  child  is  born.  The  reason  syphilis  is  not  generally 
transmitted  to  the  third  generation  is,  that  if  the  quantity  of  poison  in 
the  child  is  great  and  the  quality  intense,  the  baby  does  not  survive. 
If  it  is  less  powerful,  the  child  overcomes  it,  throws  it  off,  or,  at  least  gets 
so  far  along  in  the  tertiary  stage  before  it  has  reached  the  age  at  which  it 
can  marry  and  have  a  child,  that  transmission  to  the  third  generation  is 
very  seldom  encountered.  I  have  a  case  now  under  observation  in  which 
I  expect  finally  to  prove  transmission  to  the  third  generation;  but  the 
facts  are  not  yet  ripe  for  mature  conclusions,  and  I  withhold  them.  Hutch- 
inson  *  believes  he  has  seen  one  instance  of  transmission  in  the  third  gen- 

1  Journ.  de  med.  de  Lyon,  May,  1864. 

8  Annales  de  dermatologie  et  de  syphiligraphie.     T.  8,  No.  3,  p.  161. 

3  Verhandlungen  der  phys.  med.  Gesellschft.  in  Wiirzburg.    Vol.  III.,  1852,  p.  391. 

4  Reynolds's  System  of  Medicine.     I.,  p.  100. 


74  THE   VENEREAL   DISEASES. 

eration.  Simon,  in  the  debate  on  syphilis  before  the  London  Pathological 
Society  in  1876,  thought  he  had  seen  a  case.  Lewin '  reports  a  case,  and 
Atkinson,  of  Baltimore,  another.9 

Enough  evidence  from  different  quarters,  therefore,  seems  to  have 
been  collected  to  decide  that  syphilis  may  be  transmitted  to  the  third 
generation. 

1  Wien.  med.  Presse.     No.  1,  1876. 

*  Archives  of  Dermatology,  Jan.,  1877,  p.  106. 


CHAPTER  III. 

SYPHILIS. 

Methods  of  Contagion  in  Acquired  Syphilis,  Direct  and  Mediate. — The  Duration  of 
Syphilis  and  the  Question  of  Marriage. — CauterisatioProvocatoria. — The  Prognosis 
of  Syphilis,  and  the  Influence  of  Constitution  and  of  Intercurrent  Physiological 
and  Pathological  Conditions  upon  its  Course  and  Duration. — Second  Attack  of 
True  Syphilis  occurring  in  Individuals  who  have  already  once  had  Syphilis. 

THE  methods  by  which  syphilis  may  be  acquired  are  many.  They 
have  been  foreshadowed  in  the  last  chapter  during  the  consideration  of 
the  transmission  of  syphilis  by  inheritance,  and  of  the  fluids  which  con- 
tain the  poison.  On  the  methods  of  acquiring  syphilis  by  inheritance, 
nothing  more  will  be  said;  the  present  section  deals  with  syphilis  acquired 
by  contagion. 

Syphilis  may  be  acquired  by  contact  of  a  surface  capable  of  absorption 
upon  any  part  of  the  body  with  the  poison  of  syphilis  as  contained  in  any 
of  the  fluids  capable  of  holding  it  (Chapter  II.),  whether  those  fluids  are  at 
the  time  upon  the  body  of  the  person  yielding  the  poison,  or  upon  some 
indifferent  object.  This  opens  the  subject  of  direct  and  mediate  conta- 
gion. _ 

Direct  contagion. — Syphilis  acquired  by  sexual  intercourse  in  the 
usual  way  is  an  instance  of  direct  contagion.  The  surface  capable  of  ab- 
sorption upon  the  healthy  person  is  brought  into  direct  contact  (usually) 
with  the  source  of  the  poison.  But  there  are  many  methods  of  direct 
contagion  other  than  that  by  sexual  intercourse;  as  illustrating  these 
methods  may  be  instanced:  the  chancre  of  the  lip,  acquired  by  kissing,  a 
mucous  patch  being  the  source  of  the  poison;  the  digital  chancre  of  the 
surgeon,  acquired  while  manipulating  poisoned  parts;  or  of  the  accoucheur, 
acquired  while  practising  the  vaginal  touch ;  the  chancre  on  the  nipple  of 
the  healthy  nurse,  taken  from  the  mucous  patch  in  the  mouth  of  the  syph- 
ilitic child,  and  vice  versa.  Such  examples  might  be  multiplied  indefi- 
nitely. 

Mediate  contagion. — Puche's  often-quoted  case  is  an  excellent 
instance  of  mediate  contagion,  the  healthy  prepuce  acting  as  the  medium: 
A  married  man  with  a  long  prepuce  has  intercourse  with  a  former  mis- 
tress. He  returns  home  unwashed,  and  repeats  the  sexual  act  with  his 
wife,  leaving  in  her  vagina  some  syphilitic  secretion  which  he  had  ob- 
tained from  the  mistress,  and  carried  in  the  folds  of  his  prepuce.  The 
man  escapes  infection,  but  his  wife  acquires  chancre.  Spoons  and  forks, 
cups  and  tobacco-pipes,  tattooing-needles  (p.  G4),  are  well-known  media 
of  contagion,  receiving  saliva  which  contains  the  secretions  from  mu- 
cous patches  in  the  mouth,  and  depositing  it  upon  a  fissure  int  he  lip 
of  another  person.  All  hetero-inoculations,  for  purposes  of  experiment 
or  otherwise,  are  instances  of  mediate  contagion.  In  the  industry  of 


76  THE    VENEREAL   DISEASES. 

glass-blowing,  the  passage  of  the  tube  from  mouth  to  mouth  has  been 
known  to  effect  a  widespread  distribution  of  the  poison.  There  are 
some  grounds  for  believing  that  a  new  cigar  may  retain  in  an  active 
state,  at  its  twisted  end,  some  of  the  syphilitic  poison  derived  from  the 
mouth  of  the  man  who  originally  rolled  it — wetting  the  twisted  end,  as 
is  often  done,  with  saliva.  Vaccination  as  a  means  of  mediate  contagion 
has  already  been  noticed.  Surgical  instruments  have  sometimes  been 
the  medium  of  contagion.  Hardy  states  1  that,  in  1876,  a  specialist  in 
ear  disease,  in  Paris,  is  believed  to  have  inoculated  thirty  or  forty  persons 
with  the  Eustachian  catheter.  He  (Hardy)  had  treated  five  of  these. 
Wet  cups  have  carried  the  disease,  the  transplantation  of  teeth  has  done 
the  same,  and  the  practice  of  the  religious  rite  of  circumcision. 

A  knowledge  of  the  variety  of  methods  'by  which  syphilis  may  be 
conveyed  is  of  great  value  to  the  patient,  who  is  ordinarily  ignorant  of 
it.  It  is  well  to  instruct  him  in  this,  as  well  as  to  give  him  directions 
about  the  local  and  general  treatment  of  his  disease,  so  that,  while  curing 
himself,  he  may  know  how  to  preserve  those  by  whom  he  is  surrounded 
from  infection. 

The  duration  of  syphilis,  and  the  question  of  marriage. — 
Zeissl  is  reported  to  have  once  made  the  statement  that,  if  a  man  has 
syphilis  once,  he  has  it  for  ever,  and  that  his  ghost  after  death  will  still  be 
syphilitic.  Fournier  has  reported  a  case  where  a  gummy  tumor  on  the 
thigh  appeared  fifty-five  years  after  chancre.  In  face  of  this  strong  as- 
sertion and  this  authentic  case,  each  emanating  from  a  gentleman  occu- 
pying an  authoritative  position  in  the  profession,  who  shall  say  that  syph- 
ilis ever  gets  well,  and  not  stand  condemned  by  his  own  words  ? 

And  yet  syphilis  undoubtedly  does  get  well.  It  is  notorious  that  a 
patient  while  syphilitic  cannot  take  the  disease.  Thousands  of  inocula- 
tions have  been  made  upon  such  patients,  by  hosts  of  experimenters — 
especially  by  Boeck  and  the  syphilizers — the  matter  inoculated  being  de- 
rived either  from  syphilitic  secondary  lesions  or  from  syphilitic  chancres. 
The  result  has  been  invariably  one  of  two:  either  the  inoculation  has 
proved  negative,  or  one  of  these  two  lesions  has  followed:  (1)  an  abortive 
pustule  or  papule  sometimes  going  on  to  ulceration,  or  (2)  an  ulcer  yield- 
ing auto-inoculable  pus,  and  considered  by  some  to  be  a  chancroid.  In  no 
instance,  and  at  no  stage  of  syphilis,  has  experimental  inoculation  of 
syphilitic  virus  upon  an  infected  person  been  attended  by  the  develop- 
ment of  a  fresh  attack  of  syphilis,  with  its  characteristic  consecutive 
phenomena.  Protection  against  future  attacks  is  secured  by  a  single 
infection;  and  yet  there  are  a  number  of  cases  on  record,  resting  on  evi- 
dence which  silences  criticism,  proving  that  true  syphilis  may  be  acquired 
twice  by  the  same  individual,  and  may  in  one  lifetime  run  through  its 
different  stages  twice  (p.  83).  It  follows  that  the  first  syphilis  must  be 
well,  or  the  second  could  not  have  been  acquired. 

The  only  flaw  in  this  argument  is  that  furnished  by  the  facts  that:  (1) 
tertiary  lesions  are  no  longer  contagious,  and  do  not  involve  a  persistence 
of  the  original  poison  as  such,  or  at  least  not  in  its  original  state;  and 
(2)  occasionally  patients  still  suffering  tertiary  lesions  upon  their  persons 
bear  healthy  children.  Therefore  such  persons,  although  still  syphilitic, 
dp  not  possess  the  active  poison  of  syphilis,  and  therefore  may  take  the 
disease  again.  Consequently  it  must  be  granted  that  there  is  no  guaran- 
tee that  the  impress  received  by  the  organism  upon  the  acquisition  of 

1  Gaz.  des  hop.,  Sept  10,  1878,  p.  833. 


SYPHILIS.  77 

syphilis  is  ever  totally  eradicated,  and  that  if  the  poison,  as  a  poison, 
becomes  exhausted  by  time,  yet  the  possibility  of  after-outbreaks — if  not 
virulent,  at  least  due  to  syphilis — cannot  be  positively  denied  by  any 
honest  observer. 

This  statement  at  first  sight  seems  to  present  a  gloomy  outlook  for  the 
patient,  and  to  cast  despair  into  the  hopes  of  the  physician  in  all  his  ther- 
apeutic efforts.  But,  practically,  this  is  not  the  case.  The  treatment  of 
syphilis  is  one  of  the  few  glories  of  medicine.  It  offers  one  of  the  very 
rare  examples  of  the  specific  action  of  drugs.  A  close  knowledge  of  its 
intricate  workings  and  its  myriad  symptoms  gives  the  physician  a  breadth 
of  power  over  chronic  disease,  which  he  can  acquire  in  no  other  way. 
When  least  expected,  syphilis  crops  out  as  a  cause  of  symptoms,  which 
may  have  long  baffled  explanation,  in  a  person  whose  character  and  sur- 
roundings place  him  above  reproach.  The  multiple  means  of  mediate  con- 
tagion place  syphilis  within,  not  only  the  possibility,  but  almost  the  prob- 
ability, of  all  mankind.  The  sanctity  of  virgin  purity  does  not  shield  its 
possessor,  the  gray  hairs  of  the  sage  do  not  protect  him,  the  holy  atmo- 
sphere of  religion  is  no  barrier,  which  syphilis  by  the  aid  of  mediate  con- 
tagion may  not  easily  break  down. 

And  yet,  notwithstanding  the  widespread  prevalence  of  the  disease, 
it  is  usually  a  kindly  enemy,  and  does  not  trouble  its  victims  much  at  the 
present  day,  in  the  atmosphere  of  New  York  at  least.  Were  it  not  for 
its  treachery,  it  might  be  laughed  at,  but  it  is  eminently  respectable  in  its 
strength,  and  it  sometimes  exercises  its  power  with  a  virulence  which  is 
appalling.  It  pervades  the  whole  body,  and  may  spring  out  when  least 
expected,  and  its  possessor  has  little  safety,  except  in  that  comfort  which 
a  prolonged  thorough  treatment  affords.  No  disease  equal  to  syphilis,  in 
obstinacy  and  virulence,  yields  a  like  ready  response  to  treatment ;  and 
no  condition,  however  seemingly  hopeless,  need  excite  despair,  if  only 
syphilis  can  be  made  out  as  a  cause. 

Practically,  in  the  vast  majority  of  instances,  syphilis  is  a  very  mild 
disease.  It  gets  well,  to  all  intents,  under  a  variety  of  treatments,  or  un- 
der no  treatment  at  all  very  often;  and  the  main  advantage  possessed  by 
one  treatment  over  another  is  the  power  which  it  may  give  of  imme- 
diately controlling  symptoms  which  directly  threaten  life,  limb,  or  func- 
tions, and  the  guarantee  afforded  by  experience  in  its  use  against  relapse, 
or  serious  disease  late  in  life. 

It  is  a  less  serious  matter  to  have  syphilis  than  that  one's  father  should 
have  died  of  consumption  or  of  cancer.  Bad  malaria,  or  dyspepsia,  or 
rheumatism,  or  eczema,  or  psoriasis,  or  a  number  of  other  maladies,  are 
infinitely  worse  than  ordinary  syphilis,  far  harder  to  manage,  and  much 
more  likely  to  relapse.  The  danger  and  the  severity  of  common  syphilis 
is  much  oyerrated  by  the  profession,  as  well  as  by  the  public.  Bad  syphi- 
lis is  undoubtedly  a  horrible  disease  ;  but  there  is  very  little  bad  syphilis  in 
the  community,  compared  with  the  total  number  diseased. 

Therefore,  allowing  that  bad  cases  may  continue  to  relapse  almost  in- 
definitely, and  that  some  late  lesion,  due  to  syphilis,  may  occasionally  ap- 
pear after  any  treatment  upon  a  patient  once  affected,  even  possibly  up 
to  the  hour  of  his  death,  yet  the  common  duration  of  the  disease  is  only 
about  two  and  a  half  to  three  years,  and  many  cases  do  not  have  symp- 
toms longer  than  during  a  few  months.  After  the  first  year,  or  year  and 
a  half,  there  is  generally  but  little  trouble;  and  when  the  disease  has  fairly 
died  away,  the  patient  is  as  well  as  ever,  and  may  go  on  to  a  ripe  old  age 
without  ever  again  hearing  of  his  enemy,  having  healthy  children,  and 


78  THE   VENEBEAL   DISEASES. 

passing  through  the  changes  incident  to  advancing  life  exactly  like  any 

one  else. 

The  question  of  marriage  links  itself  naturally  to  the  question  of 
the  duration  of  syphilis.  When  may  a  syphilitic  man  marry  ?  A  man's 
life  is  not  necessarily  blighted  by  syphilis;  and  although  the  first  impulse. 
of  a  young  man,  upon  acquiring  the  disease,  is  to  forswear  matrimony, 
yet  he  changes  his  mind  after  a  time,  and  very  justly  so,  when  he  finds 
that  syphilis  is  not  the  horrible  plague  he  had  supposed  it  to  be.  The 
man  who  marries  during  the  activity  of  syphilis  commits  a  sin,  the  pen- 
alty of  which  is  paid  by  his  wife,  his  children,  and  society.  In  that  pen- 
alty he  shares,  but  he  has  no  right  to  throw  any  of  his  burdens  upon  an- 
other, especially  if  he  considers  that  other  an  object  worthy  of  any  regard. 
After  the  virulence  of  the  disease  has  become  exhausted,  then  a  man  may 
marry,  and  should  marry,  as  discharging  a  duty  due  to  society. 

The  time  at  which  marriage  becomes  justifiable  cannot  be  stated  with 
absolute  accuracy.  In  a  general  way  it  may  be  safely  said  that  a  man 
should  not  marry  until  at  least  three  good  years  lie  between  him  and  his 
chancre,  and  at  least  one  year  has  elapsed  since  the  disappearance  of  the 
last  symptom  which  can  be  ascribed  to  syphilis.  Also,  it  is  wise  for  a 
man  not  to  marry  until  he  has  passed  through  a  prolonged,  mild  mercu- 
rial course,  and  kept  himself  under  observation  for  a  number  of  months 
after  all  treatment  has  been  suspended. 

For  a  woman  the  time  should  be  longer.  She  retains  the  power  of 
producing  diseased  offspring  much  longer  than  the  male;  and,  although 
syphilis  in  the  female  is  commonly  less  intense  than  in  the  male,  it  is  on 
that  account  none  the  less  obstinate  and  protracted.  It  is  hard  to  fix  upon 
a  proper  date  at  which  marriage  may  be  allowed  in  the  syphilitic  female, 
but  it  is  safe  to  say  that  at  least  five  years  from  chancre,  and  a  prolonged 
immunity  from  symptoms  without  treatment,  should  be  insisted  upon;  that 
a  previous  prolonged  mercurial  course  shall  be  an  essential  to  obtaining 
the  physician's  consent  to  assume  a  share  in  the  responsibility  of  marriage, 
and  that  in  case  of  pregnancy  the  patient  should  submit  herself  to  the 
mild  action  of  mercury  during  the  entire  period  of  utero-gestation.  With 
these  precautions  it  will  be  reasonably  safe  for  a  syphilitic  female  to  marry. 

Cauterisatio  provocatoria.  —  An  attempt  has  recently  been  made 
by  Tarnowsky  '  to  find  a  test  of  the  existence  of  syphilis,  to  apply  to  pa- 
tients in  whom  the  disease  may  be  latent.  He  thinks  that  he  has  suc- 
ceeded; but  it  will  take  many  years  to  decide  whether  some  of  the  patients, 
upon  whom  cauterisatio  provocatoria  produced  only  a  negative  result,  may 
not  yet  develop  symptoms  due  to  syphilis. 

The  cauterisatio  provocatoria  is  an  application  of  the  well-known  prin- 
ciple that  latent  syphilis  may  be  called  into  activity  by  the  application  of 
an  external  irritant.  A  blister,  a  vaccination,  a  traumatism,  will  some- 
times call  out  symptoms  of  syphilis  upon  a  patient  apparently  well,  but 
really  in  a  condition  of  latent  syphilis. 

^  At  one  time  it  was  believed  that  a  course  of  sulphur-bathing  would 
bring  out  any  remains  of  syphilis  under  which  a  patient  might  be  suffer- 
ing, and  that  if  such  a  course  left  the  skin  sound  a  cure  might  be  confi- 
dently affirmed.  This,  like  all  other  previous  tests,  has  proved  fallacious. 

Ricord's  carbo-sulphuric  paste  was  employed  by  Tarnowsky  upon  two 
hundred  and  fifty  patients  suffering  from  chronic  maladies  of  the  skin 


>  J  Y^]'a];'™88chrift-  f'  Derm-  *•  Sypk,  rx-5  Jahresbrcht.  f.  Gesmmt.  Mei,  II.  Bd., 
Abt.  ll.,  Io7o,  p.  525. 


SYPHILIS.  79 

and  internal  organs.  The  result  of  its  action  is  summed  up  in  a  number 
of  conclusions,  some  of  which  are  in  substance  as  follows: 

(1).  A  positive  result  proves  that  syphilis  exists;  a  negative  result  does 
not  prove  the  contrary. 

(2).  A  positive  result  is  the  following:  a  dark  red  border,  not  disap- 
pearing on  pressure,  comes  on  after  all  inflammatory  action  produced  by 
the  cauterization  has  disappeared.  This  band  is  from  three  to  five  mm. 
broad.  It  has  a  sharp  border,  is  indurated,  grows  slowly,  and  acquires  a 
brown  tint.  After  twenty  to  thirty  days  it  gradually  subsides. 

At  the  same  time,  with  the  appearance  of  this  border,  a  sharp-edged 
induration  forms  beneath  the  cauterized  area.  This  increases  for  fifteen 
to  twenty  days,  and  then  gradually  disappears.  If  any  one  of  the  above 
detailed  features  is  absent,  the  cauterization  cannot  be  said  to  have  pro- 
duced a  positive  result. 

Finally,  around  the  cauterized  area,  after  the  cauterized  tissue  has 
separated,  round  or  serpiginous  ulcers,  papules,  ecthymatous  pustules,  or 
tubercles  appear,  which  go  far  to  make  more  certain  the  positive  result  of 
cauterisatio  provocatoria. 

(3).  If  the  inflammatory  results  of  the  cauterization  have  not  disappeared 
by  the  tenth  to  the  fifteenth  day,  the  first  set  of  phenomena  mentioned 
above  cannot  be  observed,  and  the  cauterization  loses  its  diagnostic 
value.  Prolonged  inflammation  is  most  apt  to  be  observed  in  non-syphili- 
tic, weakened,  cachectic  persons.  A  separation  of  the  slough  in  the  first 
five  or  ten  days  interferes  with  an  accurate  observation  of  the  result  of 
the  cauterization,  as  does  also  the  appearance  about  the  focus  of  irrita- 
tion of  eczema,  erysipelas,  etc. 

(4).  The  younger  and  the  healthier  the  individual,  and  the  less  irritable 
his  skin,  the  more  accurate  are  the  results  which  may  be  derived  from  a 
cauterisatio  provocatoria. 

(5,  6,  7).  The  nearer  the  date  of  chancre  to  the  time  of  cauterization,  the 
more  likely  is  this  test  to  give  a  positive  result,  and  to  call  out  symptoms 
of  syphilis  locally. 

I  have  as  yet  no  experience  with  this  test.  It  can  do  no  harm  to  try 
it,  but  it  will  be  unwise  to  rely  upon  the  results  attained  by  it  until  its 
accuracy  shall  have  been  tested  by  a  sufficient  lapse  of  time,  and  at  the 
hands  of  other  observers.  A  reliable  test  of  the  termination  of  syphilis 
is  very  desirable.  Koebner '  has  tried  it.  He  says  that  Tarnowsky's 
effort  is  the  revival  of  a  similar  attempt  already  undertaken  by  Meggen- 
hofen.  Koebner  tried  the  cauterisatio  provocatoria  upon  ten  syphilitic 
individuals  early  and  late  in  the  disease.  In  two  of  the  former  the  test 
was  applied  before  any  mercury  had  been  given,  but  the  result  was  nega- 
tive. Indeed,  Koebner  failed  to  get  any  positive  resxilt,  although  four  of 
his  patients  had  had  relapses  of  their  syphilis  at  the  date  of  his  writing. 
Other  investigators  will  doubtless  soon  be  heard  from.  Still  more  recently 
Kaposi  has  tried  this  test.  He  denies  its  value. 

The  prognosis  of  syphilis,  and  the  influence  of  constitution 
and  of  intercurrent  physiological  and  pathological  conditions 
upon  its  course  and  duration. — A  solution  of  this  question  explains 
many  of  the  apparent  peculiarities  of  syphilis.  If  it  were  necessary  to 
decide  which  single  quality  of  syphilis  was  more  certain  to  belong  to  the 
disease  in  all  cases  than  any  other,  the  quality  of  treachery  would  proba- 
bly be  selected.  Uncertainty  as  to  what  the  disease  may  eventually  do 

1  Vierteljahreaschrift  f.  Derm.  u.  Syph.     H.  IV.,  1878,  p.  589. 


80  THE   VENEREAL  DISEASES. 

interferes  seriously  with  accuracy  of  prognosis.  I  think  I  have  demon- 
strated this  in  another  place,1  adducing  cases  to  show  that  no  amount  of 
mildness  in  the  appearance  of  the  chancre,  or  the  course  or  symptoms  of 
early  syphilis,  is  any  guarantee  that  the  future  course  of  the  disease  will 
be  equally  light,  no  matter  which  of  the  treatments  ordinarily  in  use  is 
employed  against  the  malady.  The  seven  cases  in  the  essay  referred  to 
are  examples  of  the  mildest  forms  of  syphilis,  treated  in  all  known  ways 
except  by  the  prolonged  mild  use  of  mercury  and  by  syphilization.  I  was 
unable  to  find  a  case  where  the  mild,  continuous  treatment  had  been  used, 
which  commenced  very  mildly  and  yet  terminated  very  severely  ;  and 
syphilization  is  not  practised  in  this  country.  FournierV  record  of  forty- 
seven  cases  of  cerebral  syphilis  lends  further  weight  to  the  opinion  that 
mildness  of  the  early  course  of  syphilis  does  not  necessarily  mean  mildness 
throughout.  Of  Fournier's  forty-seven  cases,  in  only  two  did  the  syphili- 
tic symptoms  commence  severely;  one  was  moderately  severe,  thirty  were 
ordinary  cases,  and  fourteen  were  actually  benign.  The  old  notion,  there- 
fore, that  a  light  beginning  in  syphilis  can  be  counted  upon  to  indicate  a 
type  of  disease  in  itself  necessarily  mild,  is  not  accurate.  And  yet,  what 
else  is  there  to  judge  from  ?  Certainly,  a  severe  phagedenic  chancre  is 
quite  apt  to  portend  a  bad  attack  of  syphilis.  Diday's  idea  that  the 
length  of  incubation  of  the  chancre,  and  a  long  period  of  delay  in  the  ap- 
pearance of  the  secondary  symptoms,  portended  a  mild  case  of  disease,  is 
of  some  value,  but  certainly  not  absolutely  trustworthy.  As'far  as  the 
first  symptoms  show  anything,  however,  they  do  in  a  measure  declare  the 
character  of  the  subsequent  symptoms,  but  they  do  not  guarantee  it;  the 
element  of  treachery  steps  in,  and  no  honest  prognosis  can  be  a  very  posi- 
tive one. 

In  a  general  way,  then,  with  room  for  exceptions  and  leaving  out  for 
the  present  the  question  of  personal  constitutional  peculiarities,  it  may 
be  affirmed  that  a  long  incubation  to  the  chancre,  mildness  in  the  primary 
lesion,  a  long  secondary  incubation,  mildness  in  the  earliest  eruption 
(roseola) — such  qualities  in  the  early  symptoms  indicate  a  mild  type  of 
disease.  Such  a  syphilis  may  run  itself  out  in  a  few  months,  unaided 
even  by  any  treatment,  and  may  possibly  never  be  heard  from  again.  It 
often  does  appear  in  one  form  or  another  later  in  life,  but  commonly  then 
shows  the  same  light  type  as  that  in  which  it  started. 

On  the  other  hand,  a  short  incubation  to  the  chancre,  severity  in  its 
symptoms,  or  the  duration  of  the  latter,  especially  if  the  chancre  be  at- 
tacked by  phagedaena,  intensity  in  the  local  character  of  the  first  out- 
breaks (pustular  instead  of  erythematous),  and  resistance  of  the  latter  to 
treatment — particularly  that  form  of  disease  in  which  symptoms  usually 
occurring  in  the  tertiary  stage  come  on  early  in  the  course  of  the  malady 
(malignant  syphilis) — all  of  these  features  in  the  beginning  of  syphilis 
indicate  severity  in  the  type  of  the  disease,  and  the  prognosis  must  be 
modified  accordingly. 

Something  more  must  be  said  in  relation  to  both  these  classes  of 
cases — those  commencing  mildly,  and  those  commencing  severely.  It 
often  happens  that  cases  mild  in  the  quality  of  their  symptoms  are  severe 
in  regard  to  duration.  Cases  in  which  light  scaly  eruptions  occur,  and 
dry  patches,  with  persistently  relapsing  mouth  and  throat  lesions — these 

'Keyes:  Treatment  of  Syphilis,  etc.  Trans.  International  Med.  Congress,  Phila- 
delphia, 1877,  p.  726. 

1  La  syphilis  cerebrale,  etc.     L'ficole  de  nv'd.,  Aug.  30,  1875. 


SYPHILIS.  81 

often  occasion  great  annoyance  to  the  physician.  No  very  severe  symp- 
toms occur  at  any  time;  but  the  persistent  tendency  of  mild  lesions  to 
reappear  annoys  the  sufferer  greatly,  by  keeping  his  malady  before  his 
mind,  and  tests  his  patience  to  the  utmost.  In  compensation  it  may  be 
confidently  asserted  that  many  cases,  seemingly  very  severe  in  the  early 
stages,  pertinaciously  resisting  treatment,  running  to  ulceration,  and 
bringing  despair  to  the  patient — such  cases  often  expend  their  violence 
in  the  early  part  of  the  attack,  and  so  exhaust  the  virulence  of  the  dis- 
ease in  one  or  two  years,  that  the  patient  never  hears  from  it  again, 
and  passes  through  long  years  of  after-life  perfectly  sound,  bearing  only 
the  scars  to  indicate  the  ravages  occasioned  by  his  former  enemy.  This 
fact  is  undoubted,  and  a  knowledge  of  it  is  often  very  comforting  to  the 
patient. 

The  influence  of  constitution  upon  the  course  and  the  type  of 
syphilis  is  very  obvious.  Two  persons  infected  from  the  same  source  do 
not  have  exactly  the  same  type  of  disease.  Both  acquire  identically  the 
same  poison,  but  the  symptoms  are  quite  certain  to  run  a  different  course. 
This  result  can  only  be  due  to  a  difference  in  the  constitution  of  the  pa- 
tient; and  yet,  the  capriciousness  of  syphilis  shows  itself  in  this  as  in 
all  other  matters,  and  it  is  not  safe  to  be  too  positive  in  basing  a  prog- 
nosis upon  either  the  appearance  of  robust  health  or  very  obvious  consti- 
tutional defects. 

In  a  general  way,  it  is  true  that  a  healthy  person  in  good  hygienic 
surroundings,  living  a  regular  life,  is  best  able  to  stand  an  attack  of 
syphilis,  and  ought  to  escape  lightly;  while  a  sickly  person,  in  bad  sur- 
roundings, should,  by  right,  be  overwhelmed  by  the  disease.  This  is  in 
a  measure  true,  but  exceptions  are  too  common  to  make  the  fact  of  much 
value.  A  vigorous  youth  in  the  flower  of  health  may  wilt  under  the 
blight  of  syphilis,  while  a  puny  consumptive  or  a  white-blooded  dyspep- 
tic suffers  very  little  more  while  the  disease  is  upon  him  than  before  he 
acquired  it.  It  is  this  picturesque  quality  of  syphilis  which  lends  it  such 
absorbing  interest:  the  unknown  element  controls  the  issue,  and  a  prog- 
nosis, to  be  honest,  must  always  be  guarded. 

Despite  all  these  exceptions,  constitution  does,  on  the  whole,  modify 
the  course  and  intensity  of  the  symptoms  of  syphilis.  The  rheumatic 
and  the  scrofulous  tendencies  are  most  obvious  in  their  effects  upon  the 
symptoms  of  the  disease.  In  the  individual  of  so-called  gouty  habit,  the 
evolution  of  the  disease  is  slow,  the  type  of  eruptions  dry  and  scaly, 
chronic,  relapsing,  often  quite  superficial.  Many  purely  gouty  eruptions, 
especially  on  the  legs,  resemble  syphilitic  eruptions  so  closely,  that  noth- 
ing short  of  the  history  of  the  patient  and  the  result  of  treatment  can 
positively  establish  a  distinction  between  them.  Pains  and  joint  trou- 
bles, iritis,  and  bone  disease,  arterial  complications  leading  to  brain 
symptoms,  are  more  to  be  expected  in  this  class  of  patients  than  in  any 
other;  but  perhaps  the  tenacity  of  life  which  these  patients  enjoy  com- 
pensates in  a  measure  for  their  greater  tendency  to  certain  forms  of 
disease. 

The  condition  of  patients  with  phthisical  tendencies  is  nearly  always 
aggravated  by  an  intercurrence  of  syphilis. 

Scrofulous  patients  are  quite  certain  to  have  syphilis  badly.  Not 
phthisical  patients  alone — for  any  one  may  have  fibrous  phthisis,  whether 
he  is  scrofulous  or  not;  but  patients- who  are  intensely  lymphatic,  who 
run  readily  into  suppuration,  ulceration,  and  pus-formation,  who  get 
white  swelling  of  the  knee,  and  hip-joint  disease,  and  caries  of  the  spine 
6 


82  THE    VENEREAL   DISEASES. 

from  injuries,  the  effect  of  which  would  be  readily  thrown  off  by  another. 
Patients  of  this  class  have  moist  vesicular  and  pustular  lesions  early  in 
the  disease,  for  the  most  part,  and  are  prone  to  run  early  into  ulcerative 

lesions. 

Certain  lymphatic  glands  are  sometimes  involved  and  remain  indolently 
enlarged,  or  suppurate  and  communicate  with  the  surface,  remaining  long 
open  "as  ulcers  in  some  of  these  cases.  The  character  of  the  scrofulide  is 
imprinted  upon  the  syphilide,  and  the  compound  lesion  goes  through  a 
slow  evolution,  and  recovering,  yields  a  compound  scar  bearing  the  char- 
acters of  both  lesions.  Inveterate  ulcers  and  destructive  bone  disease  are 
apt  to  attend  syphilis  in  patients  of  this  class,  and  added  to  this  is  some- 
times an  intolerance  of  mercury,  which  interferes  with  treatment  and  com- 
plicates the  situation. 

Not  only  is  syphilis  influenced  by  other  diatheses,  but  in  return  it  in- 
fluences other  conditions.  Many  chronic  maladies  of  the  skin,  as  well  as 
of  the  internal  organs  and  tissues,  when  occurring  upon  a  syphilitic  patient, 
do  better  if  to  the  treatment  suitable  to  the  disease  is  added  a  certain  mild 
amount  of  anti-syphilitic  medication.  Syphilis  influences  the  healing  of 
fractures.  I  have  had  a  case,  and  have  personal  knowledge  of  another, 
both  in  the  thigh,  where  the  fracture  would  not  solidify  until  the  patient 
had  been  put  under  the  influence  of  large  doses  of  the  iodide  of  potassium, 
although  in  neither  case  at  the  time  was  the  patient  suffering  from  any 
obvious  symptom  of  syphilis.  H.  L.  Petit '  has  an  analogous  case  quoted 
from  Dron;  and  Zeissl,  another  quoted  from  Swediaur;  Barnes,  another 
in  the  London  Lancet,  for  1873.  II.,  No.  18. 

Sometimes  ordinary  wounds  upon  a  syphilitic  person  fail  to  do  well, 
and  if  irritated,  assume  the  character  of  syphilitic  ulcers  (Petit,2  Sturgis3 ) ; 
but  this  is  exceptional  rather  than  the  rule. 

As  for  the  prognosis  of  syphilis  relative  to  the  question  of  transmission 
by  inheritance,  it  may  be  confidently  asserted  that  the  malady  wears  itself 
gradually  out,  and  that  finally,  in  most  instances,  the  patient  becomes  en- 
tirely capable  of  bringing  healthy  children  into  the  world. 

Prostrating  and  excessive  work,  irregular  habits,  excess  of  any  kind, 
dissipation,  bad  hygiene,  poor  food,  insufficient  clothing,  over-treatment 
(by  excess  of  drugs),  under-treatment  (of  too  short  duration),  no  treat- 
ment, bad  treatment — all  tend  to  aggravate  the  general  prognosis. 

Sex  influences  prognosis  greatly.  Women  are  more  apt  to  become 
anaemic  than  men,  and  to  grow  greatly  debilitated.  Their  symptoms  are 
not  nearly  so  characteristic  of  the  disease  as  a  rule,  but  the  duration  of 
syphilis  with  them,  and  the  periods  of  latency,  are  seemingly  longer. 
Pregnancy  aggravates  syphilitic  symptoms  temporarily.  The  power  of 
transmission  by  inheritance  is  certainly  longer  retained  by  the  female  than 
by  the  male.  The  light  character  of  the  active  symptoms  of  syphilis  in 
the  female  makes  it  much  easier  for  the  physician  to  fail  to  detect  the 
disease  when  present,  and  for  the  patient  to  ignore  it  when  its  activity 
has  passed.  It  is  dangerous,  therefore,  in  a  suspicious  case,  to  decide  that 
there  is  no  syphilis  in  a  female,  simply  because  she  denies  its  existence 
and  bears  no  marks  of  its  passage. 

The  age  of  a  patient  certainly  influences  prognosis.  The  activity  of 
the  disease  is  very  great  in  babyhood,  and  young  children  very  frequently 

1  De  la  syphilis  dans  sea  rapports  avec  le  traumatisme.     Brochure.     Paris,  1875. 

*  Ibid. 

3  Relation  of  Syphilis  to  the  Public  Health.     Pamphlet.     New  York,  1877. 


SYPHILIS.  83 

die  of  syphilis,  inherited  or  acquired.  Old  people,  on  the  other  hand,  have 
less  vitality  and  power  of  resisting  disease,  and  syphilis  acquired  in  ad- 
vanced life  is  therefore  often  severe,  but  rarely  directly  fatal.  Certain 
German  authorities  have  denied  this,  and  declare  that  syphilis  acquired 
late  in  life  is  ordinarily  a  mild  disease.  I  have  not  usually  found  it  so. 

Boeck,  of  Christiania,  in  his  Researches  on  Syphilis,  concludes  that  the 
average  duration  of  life  in  syphilitics  is  less  than  in  persons  not  so  af- 
fected, and  believes  also  that  syphilis  when  acquired  late  in  life  is  a  less 
serious  matter  than  it  proves  at  a  younger  age.  He  thinks  that  syphilis 
acquired  by  infants  is  not  often  grave,  and  that  the  most  malignant  forms 
occur  upon  persons  between  the  ages  of  twenty  and  thirty.  In  these  con- 
clusions, excepting  possibly  the  first,  Boeck  is  at  variance  with  many  other 
observers. 

The  truth  is  that  syphilis  is,  in  most  cases,  a  very  manageable  disease, 
and  prognosis  is  more  influenced  by  the  intelligence  exercised  in  treating 
it  than  it  is  by  all  other  circumstances  combined;  but  there  are  occasional 
exceptions  to  this  rule,  as  there  are  to  all  others  relating  to  syphilis. 

Reinfectio  syphilitiea. — Second  attacks  of  true  syphilis  unques- 
tionably do  occur.  This  is  not  more  strange  than  second  attacks  of  other 
maladies,  one  course  of  which  generally  protects  a  patient  for  life,  such 
as  small-pox,  scarlet  fever,  measles,  vaccinia,  etc.  Zeissl,1  in  1858,  first 
called  general  attention  to  the  fact  that  true  syphilis  may  be  acquired 
and  run  through  its  course  twice,  and  since  that  time  a  host  of  other  ob- 
servers have  brought  forward  cases  to  swell  the  list.  Koebner 2  collated 
forty  cases,  Gascoyen 3  eleven,  Caspary  *  three,  and  numbers  of  other  ob- 
servers one,  two,  and  three  cases.  Diday  5  says  that  he  personally  saw 
twenty  cases  and  he  collected  five  others.  He  believes  that  generally  the 
course  of  the  second  malady  is  very  mild,  although  two  among  his  twenty 
ran  a  severe  course  in  the  second  attack.  In  both  of  these  cases  the  inter- 
val between  the  two  infections  was  nearly  twenty  years.  In  some  of 
Diday's  cases,  when  the  second  chancre  appeared  the  patient  still  was  suf- 
fering from  tertiary  symptoms  remaining  over  from  the  last  attack. 

An  attentive  reading  of  most  of  these  cases  of  so-called  second  infec- 
tion makes  it  clear  that  there  is  no  second  attack  at  all,  but  that  that 
form  of  pseudo-chancre  exists  (already  described,  p.  26)  which  is  not 
at  all  uncommon,  is  really  a  small,  solitary,  ulcerated  gumma  of  the  penis, 
and  is  very  frequently  observed  late  in  syphilis,  even  upon  patients  who 
do  not  practise  sexual  intercourse  at  all.  Thus,  in  fourteen  out  of  Diday's 
twenty-five  cases,  he  states  that  there  was  an  ulcer  with  characteristic  in- 
duration, but  that  the  inguinal  glands  did  not  become  indurated,  and  no 
further  sign  of  syphilis  followed.  Surely  a  mild  syphilis  this — certainly 
no  fresh  attack  at  all. 

Several  of  Koebner's  cases  and  of  Gascoyen's  also,  are  open  to  the 
same  criticism  as  Diday's  cases,  so  that  second  attacks  of  true  syphilis  are 
not  so  common  after  all.  But  second  attacks  certainly  do  occur.  Hutch- 
inson's  case,  observed  in  a  physician,  cannot  be  questioned  ;  and  many 
others  equally  convincing  exist,  where  for  a  second  time  a  patient  has  had 
an  indurated  chancre  after  a  long  period  of  incubation,  followed  by  gan- 

1  Lehrbuch  der  Syphilis,  2d  ed.,  p.  58,  1872. 
!  Berliner  klin.  Wochenschrift,  46,  1872,  p.  549. 
3  Med.  Times  and  Gaz.,  Dec.  5,  1874. 

*  Deutsche  med.  Woch.,  and  Vierteljahresschrift  f.  Derm.  u.  Syph.,  1,  1876. 

*  Archives  gen.  de  med.,  July  and  August.  1863. 


84  THE   VENEREAL   DISEASES. 

glionic  engorgement,  secondary  eruptions,  and  lesions  upon  the  mucous 
membranes  passing  through  a  course  characteristic  of  syphilis.  While, 
then,  it  must  be  granted  that  second  attacks  of  true  syphilis  do  really 
occur,  although  very  exceptionally,  it  is  fair  to  conclude  that  many  of  the 
reported  cases  of  second  attack  are  instances  of  one  of  the  forms  of 
pseudo-chancre,  and  not  second  attacks  of  syphilis  at  all. 

The  only  reported  case  with  which  I  am  familiar,  in  which  a  person 
with  inherited  syphilis  acquired  syphilis  again,  is  one  reported  by  Hutch- 
inson  in  his  article  on  syphilis,  in  Keynolds's  System  of  Medicine. 


CHAPTER  IV. 

SYPHILIS. 

The  Incubation  of  Syphilis. — Description  of  Syphilitic  Chancre :  the  Haw  Erosion, 
the  Superficial  Ulcer,  the  Herpetiform  Chancre,  the  Mixed  Chancre,  Chancre  of 
the  General  Integument,  Chancre  of  the  Lip,  of  the  Nipple,  of  the  Urethra. — 
Syphilis  without  Chancre. — Typical  Course  of  Chancre. — Specific  Induration, — 
Complications  of  Chancre  by  Phagedaena. — Treatment  of  Chancre  by  Excision 
and  other  Means. — The  Lymphangitis  of  Chancre. — The  Bubo  of  Syphilis,  and 
its  Treatment. 

The  incubation  of  syphilis  is  that  period  of  rest  which  always  oc- 
curs between  the  absorption  of  the  virus  and  the  appearance  of  the  chan- 
cre at  the  spot  where  absorption  took  place.  Its  average  duration  is 
twenty-one  days,  and  it  has  been  known  to  occupy  nearly  all  the  inter- 
mediate points  between  ten  days  (case  of  Lindmann)  and  fifty-six  days 
(von  Sigmund),  one  special  case  having  been  reported  by  Fournier  where 
the  incubation  seems  to  have  lasted  for  seventy-five  days.  Fournier 
quotes  another  from  Guerin  of  seventy-one  days. 

This  period  of  rest  between  the  time  of  exposure  and  the  time  at 
which  the  disease  shows  itself  is  one  of  the  peculiarities  of  maladies  due 
to  the  absorption  of  a  poison  (small-pox,  hydrophobia,  scarlet  fever)  in 
which  the  blood  becomes  involved.  It  seems  to  require  a  certain  time, 
after  the  poison  has  gained  access  to  the  absorbent  lymphatics  and  veins, 
before  it  can  ripen  sufficiently  to  occasion  even  a  local  outbreak  of  dis- 
ease. This  local  outbreak  in  syphilis  always  occurs  at  the  point  of  en- 
trance of  the  poison,  and  the  disease  continues,  apparently,  confined  to 
this  point  for  a  period  of  so-called  second  incubation,  after  which  its 
symptoms  become  generalized.  How  different  is  this  course  from  that 
immediate  local  poisoning  of  the  tissues  found  in  chancroid! 

The  large  number  (nearly  fifty)  of  well-recorded  authentic  cases  of 
experimental  inoculation  of  secretions  capable  of  producing  syphilis  upon 
patients  who  were  capable  of  taking  the  disease,  has  solved  this  question, 
and  made  the  incubation  period  one  of  the  most  fixed  of  all  the  facts  of 
syphilis.  Confrontations  have  done  as  much  to  establish  the  period,  and 
accurate  clinical  observation  by  skilled  and  reliable  observers  has  finally 
confirmed  the  fact  beyond  dispute. 

Why  the  time  of  incubation  varies  so  much  is  not  known.  The  short- 
est authentic  case  on  record  is  that  of  Lindemann.  He  had  been  inocu- 
lating himself  with  chancroidal  pus,  and  finally  took  some  pus  from  an 
ulcer  upon  the  tonsil  of  a  syphilitic  friend.  The  period  of  incubation  of 
his  chancre  is  put  down  as  ten  days;  but  the  second  incubation  is  placed 
at  three  months.  This  long  second  incubation  makes  it  perfectly  reason- 
able to  explain  away  the  exceptionally  short  first  incubation  in  his  case. 
Lindemann  was,  doubtless,  capable  of  free  and  rapid  secretion  of  pus. 


86  THE    VENEREAL    DISEASES. 

That  his  skin  did  not  become  easily  "  syphilized,"  and  incapable  of  pro. 
ducing  pus  upon  inoculation  with  chancroidal  secretions,  is  shown  by  his 
2,700  successful  inoculations  upon  himself  of  the  pus  of  chancroid,  as 
recorded  by  Fournier.  Six  to  eight  weeks  is  a  very  fair  period  of  second- 
ary incubation — longer  than  the  average.  Why  may  it  not  have  been, 
then,  that  Lindemann,  being  in  a  pyogenic  state,  produced  an  ulcer  upon 
his  skin  by  inoculating  pus  from  the  tonsillar  ulcer  of  his  friend  ?  And, 
supposing  this  similar  to  his  previous  self-inoculated  chancroids,  he  sim- 
ply records  it  as  a  take.  The  true  syphilitic  character  of  the  sore  may 
not  have  appeared  until  some  days  later — a  feature  which  would  have 
lengthened  his  primary  incubation  and  shortened  the  secondary  incuba- 
tion, making  both  conform  more  nearly  to  the  type. 

Be  this  as  it  may,  ten  days  may  be  well  allowed  as  the  shortest  period 
of  incubation.  Clinically,  cases  have  been  reported  near  this  date.  I 
have  seen  a  case  where  I  believe  the  incubation  to  have  been  eleven 
(nearly  twelve)  days;  although,  in  the  great  majority  of  instances,  it  has 
been  the  full  three  weeks,  or  more.  The  incubation  in  cases  of  experi- 
mental inoculation  has  very  rarely  gone  over  the  month,  and,  in  the 
greatest  number,  has  lasted  between  three  and  four  weeks. 

During  this  period  of  rest,  as  a  rule,  absolutely  nothing  happens  of 
which  the  patient  is  conscious.  Sometimes  an  abrasion  has  occurred 
during  sexual  intercourse.  This  gets  well  in  a  few  days,  or  it  may  ulcer- 
ate slightly;  but,  finally,  everything  clears  up,  and  just  as  the  patient 
(if  his  fears  have  been  aroused)  has  begun  to  consider  himself  fairly  safe, 
at  the  spot  where  poisoning  occurred  the  primary  lesion  shows  itself, 
and  goes  on  to  full  development.  Clinically,  without  confrontation,  it  is 
often  difficult  to  establish  the  exact  limits  of  the  incubation  period,  on 
account  of  the  promiscuous  and  repeated  intercourse  which  the  patient 
has  indulged  in. 

Syphilitic  chancre. — The  initial  lesion  of  syphilis  is  a  chancre, 
which  appears  after  a  period  of  incubation  upon  the  spot  at  which  the 
poison  was  first  absorbed.  It  occurs  clinically,  under  a  variety  of  forms 
which  resemble  each  other  very  little.  There  is,  indeed,  nearly  as  great  a 
variety  in  the  local  expression  of  primary  syphilis  as  is  known  to  be  the 
case  in  secondary  syphilis.  The  simplest  method  of  giving  a  comprehensive 
view  of  these  different  primary  lesions  will  be  to  describe  in  short  detail  a 
typical  case  of  each  variety,  afterward  treating  the  subject  as  a  whole, 
and  discussing  the  different  variations  from  the  true  type,  which  may  be 
encountered,  and  the  occasional  complications.  Chancres,  as  encountered 
clinically  upon  the  male  and  female  genitals,  are:  (1)  the  raw  erosion, 
more  or  less  indurated ;  (2)  the  superficial  ulcer,  more  or  less  indurated ; 
(3)  the  deep,  funnel-shaped  ulcer,  always  indurated;  (4)  the  herpetiform 
chancre,  running  into  one  of  the  above  varieties;  (5)  the  mixed  chancre. 
The  syphilitic  chancres  of  the  lip,  of  the  nipple,  of  the  general  integument, 
also  have  their  type-forms,  and  chancres  of  the  urethra,  anus,  and  rectum 
must  be  considered. 

The  raw  erosion. — This  is  the  most  common  form  of  syphilitic  chan- 
cre. Most  estimates  place  its  occurrence  as  high  as  sixty  to  seventy-five 
per  cent,  of  all  forms.  It  is  found  in  both  sexes  on  the  integument,  as 
well  as  upon  a  mucous  or  semi-mucous  surface,  of  variable  size  from  that 
of  a  small  split-pea  to  a  large  beefy  patch  as  big  as  a  copper  penny.  The 
surface  may  be  in  any  shade  of  red.  Occasionally  it  is  of  a  light  subdued 
pink.  Generally  the  color  approaches  purple,  passing  through  all  shades 
of  lividity.  Sometimes  in  a  large  patch  extravasated  blood  makes  it  more 


SYPHILIS.  87 

dark,  or  even  pigmentation  in  an  old  patch  heightens  the  effect.  There 
ma.y  be  a  central  adherent  false  membrane  (Clerc),  but  usually  the  surface 
is  literally  raw;  not  discharging  pus,  not  ulcerated,  but  yielding  a  trifling 
discharge  of  bloody  serum. 

In  shape  this  erosion  is  oval,  or  irregularly  rounded;  perhaps  it  may 
run  along  a  natural  fissure.  Several  may  occasionally  coexist  upon  one 
patient,  appearing  simultaneously.  Induration  of  these  erosions  is  com- 
mon, less  marked  as  a  rule  in  the  female,  sometimes  partial,  sometimes 
beneath  the  whole  surface,  often  parchment-like  and  imperceptible  unless 
the  whole  integument  at  the  seat  of  the  erosion  be  lifted  up,  and  the 
lesion  gently  pinched, laterally  between  the  thumb  and  finger.  Sometimes, 
on  the  other  hand,  the  induration  is  very  prominent  and  bulges  up  above 
the  surface  like  a  solid  tubercle,  with  a  flat,  raw  top. 

The  superficial  ulcer. — This  form  of  primary  lesion  is  very  common, 
and  is  much  like  the  last  in  most  of  its  features.  In  fact,  many  chancres 
are  first,  erosions,  then  ulcerate  superficially,  and  perhaps  later  return  to 
the  eroded  state.  The  only  difference  between  the  chancre  and  the  ero- 
sion is  that  this  form  is  ulcerated.  The  ulcer  is  slight,  its  borders  are 
adherent  and  sloping.  Its  underlying  induration  may  be  parchment-like, 
is  more  apt  to  be  of  split-pea  variety,  or  there  may  be  an  elevated  tuber- 
cle with  a  dome-like,  ulcerated  cap.  Finally,  the  induration  may  be 
slightly  excavated  downward,  and  then  the  ulcerated  surface  is  corre- 
spondingly depressed.  The  floor  of  these  ulcers  is  grayish,  the  discharge 
scanty,  thin,  sero-purulent — perhaps  bloody. 

The  Hunterian  chancre,  formerly  looked  upon  ^,s  a  type,  is  almost 
rare  enough  to  be  an  exception.  It  is  simply  a  very  pronounced  chancre 
of  the  variety  last  described,  where  the  induration  is  considerable  and  the 
excavation  proportionately  great.  This  chancre  is  a  large  mass  of  woody 
induration,  of  rounded  form,  in  the  centre  of  which  is  an  oval  or  rounded 
ulcer  extending  deeply  into  the  induration,  funnel-shaped,  with  a  pulta- 
ceous  floor,  adherent  sloping  edges,  and  yielding  a  thin,  moderate,  puri- 
form  discharge. 

The  herpetiform  chancre,  so-called,  is  very  exceptionally  rare.  In 
the  few  examples  I  have  seen  of  it  the  period  of  incubation  could  rfot  be 
satisfactorily  determined.  A  single  cluster  of  vesicles  appeared  upon  the 
inner  surface  of  the  prepuce  behind  the  corona.  These  looked  and  be- 
haved at  first  precisely  like  similar  attacks  of  herpes  from  which  the  pa- 
tient had  previously  suffered,  but  the  ultimate  course  was  very  different. 
The  little  ulcers  of  the  cluster  spread  and  ran  together;  induration  ap- 
peared under  the  base  of  the  ulcer,  which  became  quite  large;  the  ingui- 
nal glands  tardily  took  on  induration;  and  an  attack  of  true  syphilis  fol- 
lowed in  due  course.  I  have  been  unable  to  overcome  the  conviction,  im- 
pressed upon  me  by  observing  these  cases,  that  herpetiform  chancre  is 
simply  accidental  herpes,  upon  the  site  of  which,  and  before  its  ulcers 
have  healed,  syphilitic  chancre  comes  out. 

The  mixed  chancre  of  Rollet  is  a  combination  of  the  two  sores, 
the  chancroid  and  the  syphilitic  chancre.  Each  sore  runs  its  course,  and 
the  compound  lesion  possesses  the  characters  of  both.  The  mixed  chan- 
cre has  been  produced  experimentally.  The  two  cases  of  Lindwurm  arid 
Melchior  Robert  quoted  by  Rollet,  show  the  characters  of  the  mixed 
sore.  Lindwurm  inoculated  one  of  a  number  of  chancroids  upon  a  female 
patient  with  the  poison  of  syphilis.  All  the  chancroids  went  on  as  usual, 
got  nearly  well,  and  the  patient  left  the  hospital.  Later  she  returned. 
The  one  inoculated  chancroid  had  broken  out  afresh,  and  had  become 


88  THE    VENEREAL    DISEASES. 

hard.  It  remained  an  ulcer  long  after  the  others  got  well,  and  was  at- 
tended  by  an  outbreak  of  general  syphilis. 

Robert  inoculated  a  medical  student  with  the  secretion  of  a  mixed 
sore.  Auto-inoculable  soft  chancroid  followed.  When  the  first  ulcer 
had  nearly  healed,  it  reulcerated,  became  hard  at  the  base,  and  general 
syphilis  followed. 

A  mixed  chancre,  then,  may  result  from  the  inoculation  of  either  sore 
upon  the  other,  and  its  characters  will  be  correspondingly  modified  ac- 
cording to  the  period  of  development  of  either  sore;  either  one  may  be 
nearly  well  before  the  other  gets  fairly  under  way.  If  the  compound 
poison  is  inoculated,  the  chancroid  would  naturally  be  well  along  in  its 
course  before  it  assumed  any  syphilitic  features. 

Inoculation  of  the  secretion  upon  a  healthy  subject  clinically  may 
produce  chancroid  alone,  or  mixed  sore,  or,  it  is  said  [but  this  must  be 
quite  exceptional],  chancre  alone;  just  as  vaccination  from  a  syphilitic 
child  may  produce  in  the  healthy  one  either  vaccinia  alone,  or  both  vac- 
cinia and  chancre,  or  chancre  alone.  Clinically  the  mixed  chancre  is  very 
rare. 

Chancre  of  the  general  integument  occurs  as  a  flattened  papule 
or  elevated  tubercle,  or  excoriated  patch,  or  a  moist,  flat  tubercle,  or  an 
indurated  ulcer.  All  of  these  forms  have  been  seen  and  studied  in  con- 
nection with  experimental  auto-  and  hetero-inoculations,  and  they  may  be 
encountered  clinically.  The  lesions  resemble  the  same  varieties  upon  the 
penis.  The  excoriations  are  often  in  part  or  totally  scabbed  over;  there 
may  be  nothing  more  than  an  insignificant,  dry,  scaling  papule  upon  the 
skin  to  mark  the  point  of  entrance  of  syphilis.  The  flat,  moist  tubercle 
resembles  exactly  the  condyloma — the  flat,  mucous  tubercle  of  the  skin. 
I  have  seen  a  number  of  them  at  a  time  upon  the  skin,  as  the  initial 
lesion  of  syphilis — some  dry,  some  moist,  some  scaling,  all  livid,  raised, 
flat,  and  none  of  them  markedly  indurated.  Finally,  a  superficial  or  a 
deep  excavated  ulcer  may  mark  the  starting-point  of  syphilis  upon  the 
skin,  and  in  such  case  the  induration  of  the  ulcer  is  apt  to  be  quite  exten- 
sive. 

Chancre  of  the  lip  is  generally  a  globular  mass  of  induration  as 
large  as  a  marble,  with  an  excoriated  or  exulcerated  surface.  I  have  seen 
two  lesions  of  this  sort,  both  upon  young  girls,  both  acquired  innocently 
from  a  lover's  kiss.  The  only  other  case  I  have  seen  was  on  the  lip  of  an 
old  Frenchman.  The  chancre  in  this  case  was  a  deep  ulcer,  acquired  by 
smoking  the  pipe  of  a  companion.  It  was  large,  oval,  ragged,  and  much 
indurated. 

Chancre  of  the  nipple,  acquired  by  nursing  a  syphilitic  child,  may 
be  a  large,  deep,  indurated  ulcer,  a  brawny  excavation,  an  excoriated  or 
ulcerated,  indurated  fissure,  or  a  flat,  mucous  papule  more  or  less  livid, 
moist,  or  dry,  scaly  or  scabbed,  sometimes  but  little  indurated.  I  have 
reported '  a  case  where  the  last-named  lesion  occurred  in  a  multiple  form. 
Both  nipples  were  involved,  four  chancres  being  on  one  side,  eight  on 
the  other.  Fournier  *  has  published  one  case  with  seven  on  one  nipple, 
and  sixteen  on  the  other,  and  another  case  of  extensive  phagedenic 
chancre  of  the  nipple  derived  from  contact  with  a  mucous  patch.  The 
mother  of  a  child  with  inherited  syphilis,  although  she  may  never  have 
shown  any  symptom  of  having  had  syphilis,  cannot  acquire  chancre  at 


1  Archives  of  Dermatology,  April,  1878,  p. 
5  Gaz.  des  hop.,  Dec.  1,  1877,  p.  1109. 


126. 


SYPHILIS.  89 

the  nipple  by  suckling  her  own  child  with  mucous  patches  in  its  mouth 
(Colles's  law). 

Urethral  chancre. — I  have  observed  two  cases  of  urethral  chancre, 
one  of  them  through  the  endoscope.  By  the  tube  of  this  instrument  the 
inside  of  the  urethra  may  be  inspected,  and  the  round  flat  ulcer  seen. 
Generally,  urethral  chancre  is  situated  just  within  the  meatus,  one  of  the 
lips  of  which  it  may  involve.  Occasionally,  however,  it  occurs  at  a  con- 
siderable distance  within  the  canal.  In  my  own  case  '  the  ulcer  was  sit- 
uated upon  the  roof  of  the  urethra,  one  and  one-quarter  inch  from  the 
meatus.  By  exactly  what  mechanism  the  virus  reaches  such  a  deep  posi- 
tion, it  is  not  easy  to  imagine. 

Generally,  urethral  chancre  discloses  its  existence  by  the  presence  of 
a  lump  along  the  course  of  the  urethra,  usually  painful  upon  erection.  At 
this  spot  some  pain  is  apt  to  be  complained  of  on  urinating.  A  slight 
discharge  flows  from  the  urethra,  more  mucoid  than  purulent,  sometimes 
bloody.  This  discharge  commences  at  a  considerable  interval  after  the 
sexual  contact  to  which  it  was  due.  The  slight  discharge  continues  for 
a  number  of  weeks,  and  the  scar  left  by  the  chancre  may  subsequently  oc- 
casion more  or  less  stricture  of  the  urethra.  The  inguinal  ganglia  are 
indolently  enlarged  and  indurated. 

Syphilis  without  chancre  does  not  exist,  except  as  acquired  by 
inheritance,  and  possibly  by  mothers  in  the  so-called  choc  en-retour  pro- 
cess. Under  all  other  circumstances  syphilis  commences  with  some  sort 
of  a  lesion  at  the  point  of  entry  of  the  poison.  Since  concealed  chancres 
have  been  better  understood,  and  the  specific  character  of  the  enlarge- 
ment of  the  lymphatic  ganglia  in  the  neighborhood  of  the  primary  lesion 
more  closely  studied,  it  is  easier  to  get  upon  the  track  of  a  chancre  than  it 
was  formerly.  Chancres  are  known  to  occur  at  the  orifice  of  the  Eustachian 
tube  (by  inoculation),  upon  the  finger,  in  unexpected  places,  deep  in  the 
vagina,  in  the  rectum,  in  the  urethra;  they  have  been  observed  in  all  these 
situations,  and  spontaneous  syphilis  (without  chancre)  is  much  less  talked 
about  now  than  formerly. 

The  course  of  typical  syphilitic  chancre,  uncomplicated,  is  about 
as  follows:  The  first  sign  of  a  positive  result  of  an  inoculation  of  syphili- 
tic virus  upon  the  skin  of  a  healthy  subject  is  a  flat,  dry  redness,  or  a 
raised,  hard  papule,  red  on  top.  Generally,  upon  a  mucous  membrane,  an 
excoriation  or  a  small  superficial  ulcer  is  found  from  the  start.  Sometimes 
a  mass  of  induration  forms  first,  and  this  afterward  excoriates  or  ulcer- 
ates. On  a  mucous  membrane  a  vesicle  or  a  pustule  may  precede  the 
shedding  of  the  cuticle  which  leads  to  the  excoriation,  but  its  existence 
is  ephemeral;  it  is  usually  only  an  epiphenomenon.  Induration  of  the 
base  may  precede  the  breakage  of  the  cuticle,  and  be  excessive  as  com- 
pared to  the  latter;  or  the  opposite  condition  may  obtain,  there  being 
considerable  ulceration  after  matters  have  progressed  for  a  time,  and 
very  little  hardness.  Exceptionally,  the  whole  prepuce  becomes  stiffened 
with  a  cartilaginous  induration.  An  acute  erysipelatous  flush  of  the  in- 
tegument may  precede  this  induration,  or  the  latter  may  form  gradually, 
especially  if  the  chancre  involve  the  prepuce  near  the  frenum. 

In  the  female,  around  the  ostium  vaginas  and  on  the  labia,  erosions, 
often  not  appreciably  indurated,  excoriations,  flat,  raised  mucous  tubercles, 
and  the  regular  deep  indurated  ulcer,  may  each  be  encountered  as  the 
herald  of  future  syphilis. 

1  Am.  Journ.  of  Dermatology  and  Syphilography,  1871,  p.  37. 


90  THE    VENEKEAL    DISEASES. 

The  erosion  or  ulcer  increases  in  size  for  a  varying  period  and  to  a 
varying  extent;  from  an  erosion,  through  irritation,  it  often  becomes  an 
ulcer.  °It  remains  unique,  not  poisoning  the  integument  in  the  neighbor- 
hood, and  not  giving  any  pain;  yielding  its  watery  discharge,  attended 
by  its  lymphangitis  and  its  adenitis  in  the  second  week,  and,  after  last- 
ing from  two  or  three  weeks  to  as  many  months,  it  finally  gets  well, 
leaving  no  trace  in  most  instances.  If  the  ulcer,  however,  has  eaten 
through  the  papillary  layer  of  the  skin,  if  it  has  been  phagedenic  at  all, 
then  a  scar  is  left,  proportionate  in  extent  to  the  amount  of  tissue  de- 
stroyed. These  scars  often  remain  indurated  for  a  considerable  period. 
They  are  not  customarily  pigmented. 

Auto-  and  hetero-inoculation  of  a  syphilitic  chancre  are  both 
possible. — So  much  has  already  been  said  upon  this  subject,  in  Part  I., 
Chapter  III.,  that  only  a  few  words  more  are  necessary.  These  few  words 
may  be  concisely  arranged  in  the  form  of  separate  propositions,  the  truth 
of  which  seems  undoubted,  in  consideration  of  the  experimental  and  clin- 
ical evidence  upon  which  they  are  based. 

(1.)  Hetero-inoculation  of  the  watery  discharge  of  an  unirritated  chancre 
upon  a  healthy  person  produces  only  a  syphilitic  chancre  after  a  period 
of  incubation,  and  the  patient  becomes  syphilitic. 

(2).  Hetero-inoculation  of  pus,  taken  from  a  suppurating,  ulcerated,  or 
irritated  (Lee,  Boeck)  syphilitic  chancre,  upon  a  healthy  person,  produces 
often  an  abortive  pustule  which  gets  well,  and,  after  the  natural  incuba- 
tion, syphilitic  chancre  at  the  same  spot  follows.  If  the  person  be  in  a 
pyogenic  condition  the  first  abortive  pustule  may  ulcerate,  and  the  pus 
from  this  first  ulcer  may  be  auto-inoculable  through  a  few  generations 
(Daniellsen's  case). 

(3).  Hetero-inoculation  of  pus  from  a  suppurating,  irritated,  syphilitic 
chancre,  upon  a  person  already  syphilitic,  generally  produces  an  ulcer 
quite  freely  auto-inoculable  in  generations,  and  much  resembling  chan- 
croid (Boeck).  Inoculation  of  pus  from  this  lesion  upon  a  healthy  per- 
son has  produced  an  ulcer,  in  one  case  at  least,  which  was  auto-inoculable 
and  not  followed  by  syphilis.  An  explanation  of  this  occurrence  has 
been  offered  in  Chapter  I.,  Part  I.,  p.  4. 

(4).  Auto-inoculation  of  pus  from  a  suppurating  chancre  acts  exactly 
like  hetero-inoculation  upon  a  syphilitic  subject,  the  extent  of  the  ulcers 
and  amount  of  the  suppuration  being  dependent  upon  the  pus-forming 
tendencies  of  the  individual. 

(5).  Auto-inoculation  of  the  watery  discharge  from  an  unirritated  syphi- 
litic chancre  is  absolutely  negative,  excepting  under  two  circumstances  : 

(a).  When  the  chancre  is  quite  young,  and  the  organism  presumably 
not  saturated  with  syphilis,  some  of  the  poison  taken  from  the  patient's 
own  chancre  may  be  successfully  auto-inoculated,  producing  a  second 
characteristic  chancre  upon  him  (Puche,  Wallace,  Sperino,  Bidenkap, 
Lee,  and  others).  This  is  no  more  than  was  to  be  expected  ;  for  multi- 
ple hetero-inoculation  by  scarification  produces  a  number  of  simultaneous 
chancres,  and  the  same  phenomenon  is  observed  clinically,  as  in  multiple 
chancre  of  the  nipple.  Until  the  whole  organism  is  saturated  with  syphi- 
lis, both  hetero-  and  auto-inoculation  with  the  pure  virus,  unmixed  with 
pus,  may  produce  another  chancre  with  all  the  features  of  a  true  syphili- 
tic primary  lesion. 

(b).  Patients  with  a  syphilitic  eruption  often  have  a  lesion  produced 
at  a  point  which  has  been  subjected  to  local  injury.  A  burn,  friction,  or 
irritation,  will  call  out  a  papule  or  tubercle,  evidently  syphilitic,  which 


SYPHILIS.  91 

may  dry  up  and  scale,  or  may  excoriate  and  ulcerate  ;  and  this  lesion  may 
very  closely  resemble  true  chancre.  This  result  has  been  produced  by  Wal- 
lace experimentally,  the  virus  from  chancre  being  auto-inoculated  upon 
a  patient  in  the  eruptive  stage. 

Vaccine  auto-inoculation  offers  an  analogy  to  this  seeming  anomaly: 
any  number  of  simultaneous  inoculations  take,  and  auto-inoculations, 
while  the  vesicles  are  yet  young,  give  a  positive  result.  Finally,  when  the 
protection  wears  out,  as  it  often  does,  reinfection  is  possible  :  the  name 
being  changed,  the  story  may  be  told  of  the  disease  we  are  discussing. 

The  specific  syphilitic  induration  is  a  feature  of  chancre  the  im- 
portance of  which  has  been  much  overrated.  It  is  not  an  absolute  essen- 
tial of  syphilitic  chancre  to  be  indurated,  although,  unquestionably,  it  is  a 
very  constant  symptom.  Induration  occurs  in  three  forms: 

(1).  The  most  common  is  the  parchment-like  induration  found  under- 
lying an  ulcer  or  an  erosion,  and  often  appreciated  with  difficulty,  unless 
the  ulcer  be  pinched  up  laterally  between  the  thumb  and  finger.  This 
variety  of  induration  is  common  in  the  female  ;  it  is  rarely  simulated  in 
other  forms  of  disease;  it  does  not  involve  the  subcutaneous  tissues,  and 
may  be  so  filmy  in  character  as  to  require  considerable  faith  to  find  it. 

(2).  The  next  form  is  characteristic,  but  not  very  common.  It  is  called 
the  split-pea  induration.  Immediately  underlying  the  ulcer  is  a  substance 
of  cartilaginous  or  woody  hardness,  like  a  split-pea,  convexity  downward. 
Its  size  varies  with  the  size  of  the  surface  lesion.  It  is  very  nearly,  in- 
deed often  absolutely,  insensitive  to  moderate  pressure.  It  does  not 
shade  off  into  the  tissues  around  it.  It  is  not  adherent  to  the  deep  fascia, 
but  it  ends  abruptly  in  all  directions,  and  is  as  cleanly  defined  as  would 
be  a  foreign  body  set  into  the  skin  attached  to  the  ulcer  by  its  upper 
surface. 

(3).  The  last  form  of  induration  is  excessive.  It  resembles  the  split 
variety  in  its  quality  and  behavior  as  to  the  surrounding  tissues,  but  it 
may  greatly  surpass  the  limits  of  the  surface  lesion,  be  convex  or  concave 
on  its  surface,  or  involve  irregular  areas  of  skin,  as  when  the  whole  pre- 
puce or  a  portion  of  it  is  involved  in  a  wood-like  hardness  in  connection 
with  chancre. 

Induration  often  precedes  the  breakage  of  the  skin,  and  very  often, 
where  it  has  been  excessive,  outlasts  the  healing  of  the  ulcer,  continuing 
perhaps  for  several  months,  or  in  the  scar  for  years.  It  may  be  of  only 
short  duration — ten  or  twelve  days,  coming  late  and  going  early.  The 
thin,  parchment-like  induration  is  the  most  transitory.  Once  commen- 
cing to  disappear,  induration  may  relapse,  and  occasionally  outstanding 
indurations  appear  in  the  neighborhood  not  connected  with  the  initial 
lesion,  but  formed  around  the  lymphatic  vessels,  and  these  indurations 
may  possibly  ulcerate  (Fournier). 

Phagedaena  destroys  induration. 

Something  like  any  of  the  above  forms  of  induration  may  appear  with 
other  lesions  than  chancre,  and,  indeed,  upon  persons  not  at  all  syphilitic. 
It  is  never  safe  to  depend  upon  this  sign  for  a  diagnosis.  It  is  most 
valuable  as  a  corroborative  symptom,  and  more  constant,  as  a  symptom  of 
syphilitic  chancre,  than  any  other  one  symptom,  except  the  length  of  the 
period  of  incubation;  and  this  latter  may  be  unattainable.  Ordinary  in- 
flammatory induration,  generally,  is  very  different  from  specific  induration. 
It  is  red  on  the  surface,  painfully  sensitive  to  pressure,  adherent  to  the 
skin  and  the  parts  beneath,  losing  itself  gradually  in  the  subcutaneous 
tissue,  with  no  clearly  defined  edge;  yet,  in  spite  of  all  the  differential 


92  THE    VENEREAL   DISEASES. 

characters,  syphilitic  induration  may  be  so  closely  simulated  by  a  non- 
syphilitic  lesion,  that,  alone  and  without  strong  corroborative  evidence,  it 
is  not  of  enough  value  to  establish  a  diagnosis  of  syphilis. 

The  induration  of  a  small  gumma  of  the  semi-mucous  membrane  of  the 
prepuce,  as  appreciated  by  the  finger,  is  sometimes  absolutely,  and  in  all 
respects,  a  typical  induration  as  found  in  the  best-marked  cases  of  syphili- 
tic chancre. 

The  complication  of  syphilitic  chancre  by  phagedaena. — Syph- 
ilitic chancre  is  rarely  complicated.  Vegetations  may  grow  up  around 
it  and  its  new  surface  may  granulate,  or  may  take  on  a  whitish  pellicle  and 
become  transformed  into  a  mucous  patch.  Some  amount  of  inflammatory 
disturbance  may  complicate  the  ordinarily  indolent  and  undemonstrative 
chancre,  leading  to  its  swelling,  pain,  suppuration,  and  giving  to  it  some' 
of  the  features  (auto-inoculability)  of  its  more  formidable  local  rival,  chan- 
croid. All  of  these  complications  need  but  to  be  mentioned  to  be  under- 
stood. The  rarer  complication  of  chancre  with  chancroid  has  been  de- 
scribed at  p.  87  in  (mixed  chancre). 

Phagedaena  complicating  syphilitic  chancre  occurs  usually  in  the  gan- 
grenous form.  If  the  whole  base  of  the  sore  is  involved,  the  induration 
disappears  in  the  phagedenic  process.  Sometimes  the  slower  form  of 
phagedaena  is  found,  but  generally  this  variety  is  not  very  extensive,  when 
complicating  a  syphilitic  primary  lesion.  A  description  of  both  forms  of 
phagedaena  has  already  been  given  at  p.  39,  in  connection  with  chancroid, 
and  nothing  further  need  be  added  here  except  an  allusion  to  the  fact 
that  mercury  internally,  although  harmful  to  phagedaana  occurring  upon 
the  patient  who  is  not  syphilitic,  is  decidedly  beneficial  to  the  phagedasna 
attacking  syphilitic  chancre. 

Bassereau  puts  the  relative  frequency  of  phagedaena  as  encountered 
with  syphilitic  chancre  at  fourteen  per.  cent.,  and  Fournier  makes  it 
about  the  same.  It  is  generally  believed  that  a  phagedenic  chancre  por- 
tends a  bad  type  of  syphilis,  and  this  is  doubtless  so,  since  phagedaena  is 
not  a  quality  of  the  peculiar  virus  with  which  the  patient  has  been  poisoned. 
The  phagedaena  is  due  to  the  patient's  own  quality  of  constitution,  and  it 
is  fair  to  suppose  that  such  a  constitution  will  suffer  from  an  attack  of 
syphilis  more  seriously  than  another.  A  phagedenic  chancre  owes  its 
origin  to  an  uncomplicated  sore  as  a  rule,  and  does  not  transmit  phage- 
dasna to  another  person. 

TREATMENT  OF  SYPHILITIC  CHANCRE. 

Clerc's  medical  student,  who  washed  himself  after  intercourse,  found 
no  lesion  for  several  days,  and  yet  had  chancre  after  twenty-eight  days' 
incubation;  Diday's  case  of  cure  of  a  syphilitic  chancre  six  hours  after 
its  appearance,  by  applying  caustic,  where,  in  spite  of  the  healing  of  the 
sore,  general  syphilis  followed;  and  Hill's  '  very  striking  case,  in  which  he 
cauterized,  with  nitric  acid,  a  torn  frenum  within  twelve  hours  after  in- 
tercourse, destroying  the  raw  surface,  but  not  destroying  the  virus,  which 
showed  itself  at  the  cauterized  point  a  month  later,  as  a  syphilitic  indu- 
ration, followed  by  secondary  symptoms — all  of  these  cases  go  to  prove 
that  when  once  the  poison  has  had  access  to  the  absorbents,  the  patient 
from  that  moment  has  syphilis  several  weeks  before  he  has  any  chan- 
cre at  all.  The  folly,  therefore,  and  the  uselessness,  of  paining  a  "patient 

1  On  Venereal  Diseases.     London,  18G8,  p  67. 


SYPHILIS.  93 

with  caustics  or  of  mutilating  him  with  a  knife,  appears  obvious;  yet  the 
subject  is  still  under  active  discussion,  and  the  last  word  has  not  been 
spoken. 

It  is  well  known  that  cauterization  will  sometimes  cure  a  syphilitic 
chancre.  Caustic  does  not  do  away  with  the  induration,  however,  and  the 
latter  may  reulcerate  after  cicatrization.  No  claim  can  be  substantiated 
which  demonstrates  that  burning  a  syphilitic  chancre  is  of  any  value  to 
the  patient,  and  therefore  this  plan  of  treatment  has  been  practically 
abandoned  by  the  profession.  A  few  still  practise  it,  but  they  belong  to 
that  extraordinary  type  of  practitioner  who  burns  every  venereal  sore  he 
encounters,  and  gives  mercury  at  the  same  time,  so  as  to  feel  pretty  cer- 
tain to  hit  right,  to  whichever  variety  of  ulcer  the  sore  happens  to  belong. 
He  treats  the  symptom  and  the  possibilities,  letting  the  diagnosis  take 
care  of  itself. 

The  excision  of  syphilitic  chancres. — The  plan  of  treatment 
which  is  exciting  most  interest  at  the  present  day  is  an  attempt  at  the 
radical  cure  of  syphilis  by  excision  of  the  chancre.  The  possibility  of  ef- 
fecting cure  in  this  manner  is  based  upon  the  theory  that  the  poison,  after 
being  absorbed,  lies  latent  locally  throughout  the  period  of  incubation,  and 
then  commences  to  increase  in  quantity,  at  first  only  locally.  After  a 
period  it  reaches  the  lymphatic  glands,  and  there  increases  and  multiplies 
again,  remaining  local  in  its  new  position,  until,  during  the  period  of  sec- 
ondary incubation,  it  has  had  time  to  infect  the  general  system,  after 
which  it  becomes  general  and  manifests  itself  by  an  eruption.  This  the- 
ory is  not  sustained  by  analogy.  Other  poisons  absorbed  into  the  body 
seem  to  become  diffused  very  promptly  through  the  blood. 

The  most  thorough  essay  upon  the  subject  of  excision  of  the  primary 
lesion  of  syphilis  which  has  appeared,  has  been  published  by  Auspitz.1 
Numerous  attempts  to  cure  syphilis  by  excising  the  primary  lesion  had 
already  been  made  by  Meyer,  1840;  Hueter,  1867;  Ulrich,  Coulson,  Lan- 
genbeck,  Thiry,  and  Vogt,  some  deciding  for,  some  against,  the  value  of  the 
method.  Auspitz  reports  thirty-three  excisions,  and,  after  excluding  ten 
for  various  reasons,  founds  his  belief  upon  what  he  claims  to  be  the  results 
in  the  remaining  twenty-three.  Out  of  these  twenty-three  he  reports  that 
fourteen  remained  free  from  syphilis.  Therefore  Auspitz  concludes  that 
the  proper  treatment  of  chancre  is  to  cut  it  out  carefully,  removing  all  the 
tissues  involved  in  the  induration,  and  those  immediately  around.  He 
further  believes  that,  even  after  the  inguinal  glands  have  become  indurated, 
excision  of  the  chancre  alone  may  effect  a  cure,  although  the  glands  are 
left  undisturbed ;  and  finally  he  states  as  his  opinion  that,  even  if  a  cure  be 
not  effected,  the  course  of  the  subsequent  syphilis  is  rendered  more  mild 
by  the  excision  of  the  primary  lesion. 

These  last  statements  seem  particularly  extraordinary,  but  in  fact  the 
whole  essay  is  unsatisfactory  upon  close  analysis.  In  the  first  place, 
Auspitz  is  well  known  to  be  a  unicist.  He  does  not  believe  that  there  are 
two  poisons,  one  of  which  produces  exclusively  chancroid,  and  the  other 
syphilis.  It  is  not  stated  for  his  twenty-three  cases  that  confrontation 
was  used  in  them  to  substantiate  the  diagnosis  of  syphilis.  The  diagnosis 
of  syphilitic  chancre  was  based  solely  upon  the  "  initial  sclerosis,"  as  he 
calls  it — a  sign  full  of  the  possibilities  of  error;  and,  if  the  histories  report 
the  cases  accurately,  several  of  them  seem  unquestionably  to  have  been 
simple  chancroids  with  hard,  inflamed  bases.  The  period  of  incubation 

1  Vierteljahresschrift  f.  Derm.  u.  Syph.,  IV.,  1877,  1  and  2,  p.  101. 


94  THE    VENEREAL   DISEASES. 

was  unknown  in  nine  cases,  or  set  down  as  less  than  ten  aays;  and  several 
of  the  cases  were  only  observed  a  few  months  after  excision — a  period 
manifestly  too  short  to  make  it  safe  to  decide  that  no  syphilis  was  present. 
Altogether  the  report  is  full  of  inaccuracies,  and,  although  in  several  of 
the  cases  the  date  of  apparent  incubation  and  the  appearance  of  the 
chancre  make  it  seem  very  probable  that  the  patient  had  syphilis,  while 
no  symptoms  followed  excision,  yet  the  possibility  of  error  was  not  guard- 
ed against  by  confrontation,  and  the  cases  at  best  remain  simply  as  nega- 
tive evidence,  while  the  nine  positive  cases,  in  which  syphilitic  symptoms 
followed  in  spite  of  excision  of  the  chancre,  are  not  explained  away  by 
Auspitz. 

Still  more  recently,  Kolliker '  has  communicated  eight  cases  of  excision 
of  chancre  for  the  prevention  of  syphilis.  Of  the  eight,  five  had  syphili- 
tic symptoms  in  spite  of  the  excision  ;  three  remained  free.  In  none  of 
the  three  was  confrontation  employed  to  establish  the  diagnosis.  One  of 
them  was  observed  less  than  four,  the  other  two  less  than  five  months. 
In  Case  V.  the  chancre  was  excised  seven  days  after  it  appeared  ;  there 
was  no  glandular  swelling  at  the  time,  yet  syphilis  followed.  In  Case 
VIII.  excision  was  practised  ten  days  after  the  chancre  appeared  ;  there 
was  an  enlarged  inguinal  gland  (only  one,  it  seems)  on  the  right  side  at 
the  time,  and  syphilis  did  not  follow.  In  one  (successful  ?)  case  the  chan- 
cre had  existed  two  weeks  ;  but  there  was  no  ganglionic  enlargement  in 
the  groin,  a  circumstance  which  opens  the  nature  of  the  chancre  to  ques- 
tion. 

Three  cases  have  since  been  reported  by  Unna,  in  one  of  which  syphi- 
lis followed.  The  cases  teach  nothing  new. 

Hence  it  may  seem  that  the  matter  is  not  yet  proved.  Doubtless 
many  experimenters  are  now  at  work  investigating  the  subject.  The 
most  certain  demonstration  would  be  for  some  gentleman,  who  had  never 
had  syphilis  and  who  believed  in  the  value  of  excision,  to  allow  himself 
to  be  inoculated  from  an  initial  lesion  upon  another.  If  this  inoculation 
was  followed  by  the  proper  interval  of  incubation,  and  then  appeared  as 
a  hard  papule,  the  latter  might  be  cut  out  and  the  result  watched. 

Up  to  this  time,  all  that  can  be  said  in  the  present  state  of  the  question 
is,  that  cutting  o.ut  the  initial  lesion  of  syphilis  can  do  no  harm,  and  may 
do  some  good.  It  should  be  placed  before  the  patient  in  this  light,  and,  if 
he  elects  excision  and  the  chancre  is  in  a  suitable  position  for  thorough 
removal,  it  may  be  excised,  precautions  being  taken  first  thoroughly  to 
disinfect  the  surface  with  carbolic  acid,  to  use  clean  curved  scissors  and 
hooked  forceps,  and  to  remove  all  the  induration,  and  a  certain  portion  of 
healthy  tissue,  at  a  single  cut.  The  after-dressing  is  unimportant.  The 
general  excision  of  syphilitic  chancres  is  yet  to  be  justified,  or  condemned, 
by  the  result  of  experiments. 

At  present  the  best  local  treatment  for  chancre  seems  to  be  black 
wash,  or  dusting  with  calomel  powder.  In  suppurating  chancres  iodo- 
form  is  serviceable.  The  mixed  sore  must  be  treated  like  a  chancroid. 
Phagedaena  attacking  a  true  syphilitic  chancre  is  favorably  influenced  by 
the  internal  use  of  mercury.  If  the  sore  is  not  syphilitic,  mercury  is  harm- 

The  internal  use  of  mercury  has  a  very  favorable  influence  in  shorten- 
ing the  duration  of  a  syphilitic  chancre  ;  but  such  treatment  is  hardly  ever 

iF^61  Elision  der  Byphilitischen  Initialsklerose.  Centralblatt  f.  Chirurgie,  Nov. 
oO,  Io7o,  p.  801. 


SYPHILIS.  95 

advisable — never  unless  the  origin  of  the  sore  has  been  ascertained  by  con- 
frontation, and  all  the  points  about  the  ulcer,  its  history,  and  its  physical 
characters,  render  ij  beyond  possible  doubt  that  its  nature  is  syphilitic ; 
and  even  then,  unless  there  is  some  excellent  reason  to  the  contrary,  it  is 
better  to  wait  for  the  first  signs  of  general  syphilis  before  commencing 
treatment. 

THE   LYMPHANGITIS    OF   SYPHILIS. 

This  consists  in  an  indolent  thickening,  with  induration  of  the  wall 
of  one  or  more  lymphatic  trunks.  The  thickening  involves  a  certain 
amount  of  the  surrounding  atmosphere  of  connective  tissue  occasionally. 
These  rigid  cords  with  occasional  knots  upon  them  may  be  felt  along  the 
sides  or  back  of  the  penis,  sometimes  part  way  from  the  chancre  back- 
ward toward  the  root  of  the  penis,  sometimes  only  perceptible  near  the 
pubic  symphysis.  The  cords  vary  in  size  with  the  amount  of  infiltration  of 
the  walls  of  the  lymphatic  trunks,  and  are  larger,  if  any  surrounding  tis- 
sue happens  to  be  involved.  Very  rarely  the  inflammatory  process  around 
the  vessels  goes  on  to  suppuration.  Generally,  the  lymphangitis,  if  it  oc- 
curs, precedes  the  inguinal  adenitis  by  a  few  days.  Rollet  thinks  it  may 
be  found,  if  looked  for,  in  almost  twenty  per  cent,  of  all  cases.  It  is,  as  a 
rule,  painless,  and  of  not  the  least  importance.  It  requires  no  treatment. 
The  integument  over  the  thickened  lymphatic  trunks  is  not  reddened. 
There  is  no  peculiar  character  by  which  this  malady  may  be  known  from 
a  chronic  mild  lymphangitis  of  the  larger  lymphatic  channels  occurring 
spontaneously,  and  having  no  connection  with  syphilis  as  a  cause.  I  have 
encountered  this  twice  upon  healthy  persons,  and  seen  it  occur  in  connec- 
tion with  non-syphilitic  lesions.  All  that  can  be  said  of  syphilitic  lym- 
phangitis is,  that  if  it  occurs  with  syphilitic  (uninflamed)  chancre,  it  is 
very  certain  to  be  peculiarly  indolent  and  painless,  and  to  be  characterized 
by  a  high  degree  of  induration.  Anatomically  the  walls  of  the  lymphatic 
channels  are  permeated  with  exudation  corpuscles.  Syphilitic  lymphan- 
gitis requires  no  treatment. 


THE    BUBO    OP   SYPHILIS. 

The  first  set  of  lymphatic  glands  along  the  line  of  absorbents  which 
originate  in  the  neighborhood  of  the  initial  lesion  of  syphilis,  almost  in- 
variably become  the  seat  of  certain  changes  which  stamp  them  with  pecu- 
liar value  as  aids  to  the  diagnosis  of  the  nature  of  the  primary  lesion. 
The  bubo  of  syphilis  may  therefore  be  situated  anywhere  upon  the  body 
where  there  is  a  lymphatic  gland,  provided  the  radicals  of  the  lymphatic 
trunks  leading  to  that  gland  originate  in  the  neighborhood  of  the 
chancre.  Thus,  chancre  of  the  lip  has  its  bubo  under  the  jaw;  chancre 
high  up  on  the  cheek,  in  the  pre-aural  gland;  of  the  hand,  in  the  epitroch- 
lear  gland;  of  the  breast,  in  the  axilla;  of  the  penis,  in  the  groin,  etc. 

The  syphilitic  bubo  almost  invariably  comes  on  during  the  second 
week  after  the  appearance  of  the  primary  lesion,  between  the  eighth  and 
eleventh  days  in  cases  of  experimental  inoculation.  One  gland  generally 
first  becomes  enlarged,  and  then  a  number  of  others,  until  (in  the  groin) 
a  cluster  of  altered  glands,  not  matted  together,  but  lying  separately,  are 
found,  constituting  what  Ricord  has  termed  a  pleiad,  and,  when  typical, 
very  distinctive  of  syphilis. 


96  THE    VENEREAL    DISEASES. 

The  number  of  glands  in  a  pleiad  varies  from  two  or  three  to  six  or 
eight.  Where  there  are  many,  one  is  usually  larger  than  the  others. 
Generally  the  glands  in  both  groins  are  involved.  Each  of  the  little 
glands  of  the  altered  group  is  quite  hard,  round  or  oval,  painless  on  pres- 
sure, not  adherent  to  the  skin  or  to  the  tissues  lying  under  or  around  it, 
and  each  is  entirely  distinct  from  the  others.  The  skin  lying  over  them 
is  not  reddened,  and  the  patient  is  unconscious  of  their  existence.  In 
size  each  gland  varies  from  that  of  a  pea  to  that  of  a  marble.  Where  the 
number  is  considerable,  the  size  of  each  is  usually  smaller  than  where  there 
are  but  few.  Occasionally,  instead  of  the  pleiad  there  is  one  very  large, 
hard,  oval  gland,  with  one  or  two  quite  small  ones;  and  still  more  rarely 
the  bubo  is  single;  an  enormous  lump  as  large  as  an  egg,  existing  in  one 
or  both  groins.  Bassereau  dissected  one  of  these  lumps,  and  found  it 
composed  of  a  mass  of  indurated  connective  tissue  enveloping  a  number 
of  indolently  engorged  glands  of  different  sizes,  between  which  ran  the 
thickened  lymphatic  trunks. 

The  swelling  of  these  glands  is  called  indolent  because  of  their  slow 
course,  their  painless  and  non-inflammatory  character.  Very  often,  how- 
ever, when  they  begin  to  swell  they  are  slightly  painful;  and  occasionally 
they  go  on  to  suppuration,  either  centrally,  or  as  a  peri-glandular  sup- 
puration. Such  abscess  is  always  simple  in  its  nature,  and,  if  open,  never 
becomes  chancroidal  like  the  virulent  bubo  of  chancroid. 

While  the  syphilitic  bubo  is  generally  multiple,  in  certain  situations 
it  is  more  apt  to  be  single,  as  under  the  chin,  under  the  jaw,  at  the  elbow, 
although  in  the  latter  situation  there  may  be  a  secondary  pleiad  in  the 
axilla. 

According  to  Rindfleisch,  the  ganglionic  induration  is  due  to  an  in- 
crease in  the  cellular  elements  of  the  gland,  more  than  to  a  thickening 
of  the  parenchyma.  These  new  cells  undergo  fatty  metamorphosis  after 
a  time,  and  are  absorbed. 

In  very  fat  people  syphilitic  bubo  is  less  marked  than  in  others.  In 
about  two  per  cent,  of  all  cases  examined  Fournier  found  it  entirely  ab- 
sent. He  thinks  that  it  may  be  absent  when  phagedaena  attacks  a 
chancre.  The  duration  of  syphilitic  bubo  varies  from  a  few  weeks  to  a 
number  of  months.  Sometimes  the  glands  never  subside  to  their  original 
size.  They  are  almost  constantly  present  during  the  first  eruption,  and 
at  this  time  they  occasionally  grow  somewhat  larger  and  harder. 

Certain  observations  have  been  made  (Fournier)  tending  to  show  that 
other  groups  of  lymphatic  glands,  lying  more  centrally  than  those  first 
involved,  become  secondarily  the  seat  of  indolent  engorgement,  at  an  in- 
terval after  the  enlargement  of  the  first  set  of  glands.  Attention  has 
only  lately  been  drawn  in  this  direction,  and  the  question  is  not  yet  fully 
solved.  Clinically  it  is  not  a  matter  of  much  importance,  since  such  seta 
of  glands  are  generally  beyond  the  reach  of  inspection.  This  is  not 
always  the  case,  however,  for  in  mammary  chancre  it  is  customary,  first, 
fcfr  a  few  glands  underlying  the  pectoralis,  on  the  chest,  to  become  in- 
durated, and  then  the  axillary  glands;  and  it  is  not  uncommon,  after  a 
digital  chancre,  for  the  epitrochlear  glandular  enlargement  to  be  followed 
by  multiple  indolent  bubo  of  the  axilla. 

The  treatment  of  syphilitic  bubo  is  that  of  general  syphilis.  No 
treatment  is  called  for  until  a  general  eruption  comes  on.  Local  meas- 
ures are  useless.  If  pain  and  inflammation  appear  as  complications,  the 
symptoms  are  to  be  appropriately  met. 


CHAPTER  Y. 

SYPHILIS. 

A  Table  giving  a  Comprehensive  View  of  the  Features,  Course,  Symptoms,  etc.,  of 
Chancroid,  as  compared  with  Similar  Conditions,  when  met  with  in  connection 
with  Syphilitic  Chancre. —The  Stages  of  Syphilis:  Primary,  Secondary,  Tertiary. 
— Malignant  Syphilis. — The  Second  Incubation. — Syphilitic  Fever. — Symptoms  at- 
tending the  Beginning  of  General  Syphilis. 

A  DIAGNOSTIC  table,  setting  forth  the  main  differential  points  of  chan- 
croid and  chancre  in  typical  cases,  has  already  been  given  at  p.  25.  The 
present  table  is  inserted  as  a  summary,  and  is  intended  to  present  a  con- 
densation of  the  whole  subject  for  easy  reference.  This  table  will  not 
serve  as  a  diagnostic  table.  A  diagnosis,  with  any  chance  of  being  accu- 
rate, can  only  be  rendered  about  a  typical  sore.  The  previous  table  will 
serve  for  this  purpose.  When  a  sore  of  either  variety  is  irregular  or  com- 
plicated, it  may  be  attended  by  so  many  features  of  both  sores  that  a  di- 
agnosis of  its  nature  becomes  absolutely  impossible.  In  such  a  case  it  is 
the  part  of  wisdom  to  reserve  judgment  and  wait  for  developments  before 
giving  an  opinion.  No  man,  who  has  confidence  enough  in  himself  to  be 
willing  to  take  the  responsibility  of  a  case  of  syphilis,  should  be  ashamed 
to  confess  ignorance  as  to  the  nature  of  a  sore  until  he  has  had  plenty  of 
time  for  studying  its  features  and  its  course.  The  following  table  is  ar- 
ranged under  each  head,  for  typical  as  well  as  for  irregular  cases. 

The  typical  description  in  the  table  is  printed  in  italics,  the  irregular- 
ities in  ordinary  type. 


CHANCROID. 

1.  Nature. — A  local  tissue  disease. 

2.  Cause. — Contamination   with    chan- 
croidalpus  in  sexual  intercourse;  accidental 
or  designed  auto-  or  hetero-inoculation  of 
chancroidal  pus;  pre-existing  virulent  bubo, 
which,  upon  opening,  becomes  a  chancroid. 

3.  Situation. — Upon  the  genitals  or  in  the 
groin  ;  very  uncommon  elsewhere. 

4.  Number. — Often  multifile  both  in  ori- 
gin, and  by  spontaneous  auto-inoculation. 

5.  Second  attack  in  the  same  individual. 
— Entirely  possible. 

6.  Auto-inoculability. — Always    possible 
in  generations. 

7.  Transmissibility  to  animals. — Possible. 

7 


SYPHILITIC  CHANCRE. 

1.  A  general  blood  disease. 

2.  Contamination  with  syphilitic  virus  in 
sexual  intei'course  ;  hetero-inoculation  upon 
a  non-syphilitic  person,  of  the  secretion  of 
a  syphilitic  chancre,  of  syphilitic  blood,  or 
of  the  discharge  from  a  mucous  patch  or 
a  secondary  syphilitic  lesion. 

3.  Upon   the  genitals;    not  uncommon 
upon  the  lips,  nipples,  and  fingers ;  very 
uncommon  elsewhere. 

4.  Generally  single*  sometimes  multiple, 
from  the  start ;  not  usually  spreading  by 
spontaneous  auto-inoculation. 

5.  Almost  impossible. 

6.  Impossible,  unless  the  ulcer  secretes 
pus. 

7.  Quite  probable. 


THE   VENEREAL    DISEASES. 


CHANCROID. 

8.  Incubation. — None.       CJianges    com- 
mence wit/iin  twenty-four  hours.     Ulcer  is 
fuUy  formed  on  the  third  day.     Sometimes 
absorption  is  delayed,  and  the  ulcer  does 
not  appear  until  after  the  end  of  a  week. 

9.  Appearance  and  course. — Commences 
as  a  pustule  or  an  ulcer,  and  remains  an 
ulcer  to  the  end.     Advances  rapidly \  heals 
slowly. 


10.  Shape. — Pounded,  oral,  or  irregular, 
if  a  fissure  has  been  inoculated  or  several 
ulcers  have  run  into  one. 

11.  Color.— Dirty  yellowish  white  or  pale 
pink. 

1 2.  Secretion. — Creamy,  free. 

13.  Edges. — Perpendicular,  often  under- 
mined. 

14.  Floor. —  Uneven,  duU. 

15.  Pain. — Often  present. 

16.  Induration. — Absent.        In      many 
cases,  however,  a  hardness,  due  to  inflam- 
mation comes  on.     This  sometimes  resem- 
bles syphilitic  induration,  but  usually  is 
quite  distinct  from  it. 

17.  Phagedaena. — An   occasional   com- 
plication. 

18.  Lymphangitis. — Not   uncommon  in 
its  simple  inflammatory  form,  tery  rare  in 
its  virulent  form. 

19.  Bubo. — Occurs  in  about  thirty-three 
per  centum  of  all  cases,  sometimes  as  simple 
bubo,  which  may  subside  or  may  suppurate; 
sometimes  as  virulent  bubo,  which  necessarily 
suppurates  and  becomes  a  cfiancroid. 

20.  Prognosis. — Syphilis,  as  a  result  of 
chancroid,  is  impossible. 

21.  Treatment. — Local  treatment  all-im- 
portant. 


SYPHILITIC  CHANCRE. 

8.  Never  less  than  ten  days ;  usually 
about  three  weeks ;  occasionally  a  little 
more  than  two  months. 


9.  Commences  as  an  excoriation  or  an  in- 
duration, and  remains  as  a  raw  erosion  or 
an  indurated  ulcer  ;  advances  slowly,  heals 
slowly.     Sometimes  it  remains  a  dry  pa- 
pule, or  is  an  ulcerated  fissure  throughout 
its  course. 

10.  Round,  oval,  or  a  fissure  ;  not  apt  to 
be  due  to  the  fusion  of  several  sores. 

11.  Livid  red,  or  brilliant  blood  color,  or 
gray;  sometimes   dirty  white,  sometimes 
scaly  or  scabbed. 

12.  Scanty,  serous,  sanguinolent,  some- 
times purulent. 

13.  Slanting,  adJierent. 

14.  Smooth,  bright,  sometimes  dull. 

15.  Generally  absent. 

16.  Present,    almost  invariably,  in   the 
male ;  more  often  absent  in  the  female. 


17.  A  very  rare  complication. 

18.  Rather  rare,  always  indolent,  excep- 
tions being  phenomenal;  never  virulent. 

19.  Invariable  (exceptions  two  per  cent.), 
always  indolent;  occasionally   attended    by 
enough  inflammation  to  end  in  suppuration, 
but  never  becoming  virulent. 

20.  Syphilis,  as  a  result  of  chancre,  is  in- 
variable. 

21.  Local  treatment  unimportant. 


THE   STAGES    OF   SYPHILIS. 


Syphilis  is  not  a  continuous  chain  of  symptoms.  It  is  a  broken  se- 
ries of  outbreaks,  varying  in  intensity,  in  duration,  and  in  the  length  of 
the  intervals  between  them.  During  these  intervals  the  patient  may  seem 
perfectly  well ;  but,  that  he  is  well  because  he  seems  well,  cannot  be  asserted. 
The  intervals  are  called  periods  of  latency  of  the  disease.  During  these 
periods,  when  they  occur  early  in  the  malady,  it  is  quite  evident  that  the 
patient  is  not  well.  After  inoculation  the  period  of  incubation  is  a  period 
of  latency,  but  surely  the  patient  is  not  then  well.  Toward  the  end  of 
the  disease,  however,  the  periods  of  latency  become  longer;  and  finally 
one  period  arrives  very  often,  which  ends  only  with  the  patient's  death 
from  some  other  cause  than  a  return  of  his  syphilis,  and  this  period  of  la- 
tency is  in  most  cases  one.  of  health;  the  patient  is  well. 

That  the  poison  continues  active  during  the  periods  of  latency  (the 
early  ones)  is  evident  from  the  fact  that  vaccinal  syphilis  has  often  been 


SYPHILIS.  99 

acquired  from  the  blood  of  a  vaccinifer  not  at  the  time  bearing  any  trace 
of  syphilis  upon  its  person;  that  syphilitic  women,  during  periods  of  most 
absolute  latency,  have  brought  forth  syphilitic  children;  that  traumatisms 
upon  syphilitics,  in  a  period  of  latency,  often  call  out  syphilitic  lesions 
(cauterisatio  provocatoria,  p.  78). 

Therefore  it  becomes  impossible  to  state  absolutely  that  the  disease 
syphilis  is  naturally  divided  up  at  all.  It  may  be  one  continuous  malady 
with  remissions,  but  really  continuing  all  the  time.  Yet  facility  of  de- 
scription, custom,  and  the  peculiar  character  of  the  outbreaks  of  syphilis, 
have  justified  its  division  into  stages,  and  these  stages  are  commonly 
known  as  primary,  secondary,  and  tertiary  syphilis.  The  attempt  to  make 
a  separate,  intermediary  syphilis,  between  the  second  and  third  stages,  has 
not  met  with  general  favor,  and  the  effort  to  christen  the  final  phenomena 
as  quaternary  has  also  miscarried.  There  remain,  therefore,  the  three 
stages  of  common  adoption:  the  primary,  the  secondary,  the  tertiary. 

Primary  syphilis  is  all  that  portion  of  the  disease  lying  between 
the  moment  of  infection  and  the  time  of  appearance  of  the  first  general 
eruption  with  its  fever  and  general  ganglionic  engorgement;  it  therefore 
includes  the  initial  lesion  with  its  accompanying  lymphangitis  and  adeni- 
tis, but  nothing  more. 

Secondary  syphilis. — As  soon  as  the  secondary  incubation  has 
passed,  secondary  syphilis  begins.  It  may  date  as  early  as  three  weeks 
from  the  time  of  appearance  of  the  chancre;  it  generally  does  not  com- 
mence for  six  weeks  or  two  months,  and  may  be  delayed  much  longer, 
especially  if  mercury  has  been  used  in  treating  the  primary  stage.  Most 
of  the  symptoms  of  this  stage  are  superficial.  They  are  first  congestive, 
leaving  no  scar,  and  occurring  on  the  mucous  as  well  as  on  the  cutaneous 
expansions.  Gradually,  as  time  passes,  the  lesions  become  deeper-seated, 
and  finally  the  second  merges  so  gradually  into  the  tertiary  stage  that  it 
is  impossible  to  fix  upon  a  positive  boundary  between  them. 

It  is  just  at  this  point  that  the  French  dermatologists  have  attempted 
to  group  together  an  intermediary  set  of  lesions  liable  to  occur  upon 
the  integument,  and  to  call  them  intermediary  syphilis;  but  it  is  more 
customary  in  this  country,"and  equally  accurate,  to  speak  of  these  symp- 
toms as  late  secondary  symptoms,  and  the  term  is  just  as  convenient — per- 
haps more  descriptive. 

The  duration  of  secondary  syphilis,  like  the  duration  of  the  whole 
disease,  varies  so  greatly  that  it  is  not  only  impossible,  but  even  unwise, 
to  attempt  to  confine  it  within  definite  boundaries.  In  a  general  way,  in 
most  cases  the  symptoms  merge  into  the  tertiary  forms  during  the  sec- 
ond year;  but  secondary  lesions  continue  in  many  cases  to  crop  out  occa- 
sionally in  the  third  year  or  later,  intermingled  with  the  deeper  lesions  of 
tertiary  disease.  It  is  not  at  all  uncommon  for  a  patient  with  a  gumma- 
tous,  destructive  ulcer  of  the  throat  to  have  also  upon  his  palm  a  superfi- 
cial scaly  patch  very  similar  to  what  he  may  have  had  during  the  first  year 
of  his  disease. 

And,  on  the  other  fiand,  but  more  rarely,  the  symptoms  legitimately 
belonging  to  tertiary  syphilis  occasionally  come  on  earlier,  and  appear 
among  the  secondary  symptoms.  Gummata  in  various  situations  may 
thus  appear  prematurely;  nodes  on  bones,  advanced  symptoms  of  nervous 
disease,  hemiplegia,  epilepsy,  sometimes  show  themselves  at  the  end  of 
six  months,  and  are  followed  by  secondary  symptoms,  instead  of  remain- 
ing in  their  regular  place  and  appearing  during  the  second  year,  or 
later. 


100  TELE    VENEREAL    DISEASES. 

These  irregular  forms  of  syphilis  have  scandalized  some  observers, 
and  made  them  wish  to  give  up  secondary  and  tertiary  distinctions  of 
symptoms,  since  the  facts  do  not  bear  out  the  theories.  But  it  is  not 
well  to  throw  away  a  good  thing  simply  because  it  will  not  serve  every 
purpose.  The  stages  of  syphilis  are  certainly  very  convenient,  and  afford 
the  student  assistance  in  his  observation  of  the  disease,  and  in  its  treat- 
ment. Therefore  they  should  be  preserved.  The  exceptions  in  syphilis 
are  its  chief  beauty;  there  is  no  monotony  about  it;  and  if  descriptions 
of  the  disease  did  not  in  their  first  plain  statements  practically  ignore 
exceptions,  there  could  be  no  descriptions  at  all,  for  there  probably  is  not 
a  single  feature  of  syphilis,  from  the  chancre  to  the  most  ultimate  symp- 
tom due  to  a  visceral  lesion,  which  may  not  be  lacking  in  a  well-marked 
case  of  syphilis. 

Tertiary  syphilis  commences  on  the  boundary  line  of  secondary 
svphilis,  somewhere  in  the  second  year  usually,  and  embraces  everything 
which  may  happen  afterward  due  to  the  disease.  The  lesions  are  infil- 
trative,  gummatous,  often  destructive,  ulcerating,  and  include  most  of  the 
connective-tissue  parenchymatous  changes  and  gummy  deposits  which  in- 
volve the  viscera. 

In  inherited  syphilis  the  symptoms  of  both  secondary  and  tertiary 
stages  are  customarily  more  or  less  combined.  The  child,  when  born, 
often  has  parenchymatous  changes  in  its  lungs,  liver,  kidneys,  thymus, 
and  spleen,  with  changes  in  the  epiphyses  of  the  long  bones,  and  at  the 
same  time  superficial,  scaly,  erythematous,  papular,  and  excoriative 
patches  upon  its  integument  and  mucous  membranes. 

In  acquired  syphilis  the  whole  of  the  tertiary  stage  may  be  absent. 
The  disease  not  uncommonly,  under  judicious  treatment,  ceases  entirely 
at  the  end  of  the  secondary  stage,  and  the  patient  lives  for  years  without 
another  symptom,  raising  healthy  children,  and  himself  to  all  appear- 
ances well.  More  rarely  the  secondary  stage  may  be  skipped  entirely — 
this  also  usually  under  treatment — and  the  disease  may  only  show  itself 
after  a  longer  or  shorter  period  of  latency  in  the  tertiary  gummatous 
stage.  I  have  seen  a  number  of  instances  of  this  sort  occurring  after  al- 
most every  variety  of  treatment,  and  after  no  treatment  at  all. 

Malignant  syphilis. — This  is.  a  final  variety,  in  which  the.  disease 
runs  riot,  respecting  no  stages,  obeying  no  rules.  Gummata  may  spring 
into  existence  within  a  few  months  after  chancre,  and  the  most  desper- 
ate late  lesions  follow  each  other  without  any  period  of  latency,  and 
respond  very  imperfectly  to  ordinary  treatment.  This  style  of  disease 
sometimes  kills;  but  it  bears  this  measure  of  comfort  with  it:  that,  if  the 
patient  survive,  he  is  apt,  though  mutilated  with  scars,  to  be  rid  of  his 
syphilis  forever.  The  malady  seems  sometimes,  in  this  way,  to  exhaust 
itself  in  its  fury,  and  to  expend  during  a  number  of  months  that  energy 
which  it  sometimes  stores  up  to  carry  itself  over  long  periods  of  years. 


THE  PERIOD  OP  SECOND  IXCUBA*TION. 

The  second  incubation  commences  when  the  chancre  appears,  and 
ends  when  general  symptoms  come  on.  This  period  often  is  not  one  of 
latency,  strictly  speaking,  since  active  symptoms  of  syphilis  are  usually 
present  upon  the  patient  during  the  whole  of  it,  for  the  chancre  has 
rarely  healed  before  the  first  eruption  comes  out  (unless  treatment  keeps 
it  back) ;  and  even  if  the  chancre  has  gone,  the  inguinal  glands  are  cer- 


SYPHILIS.  101 

tain  to  remain  engorged  during  a  much  longer  time  than  the  period  of 
secondary  incubation. 

The  length  of  the  second  incubation  in  untreated  cases  varies  from 
twelve  days,  which  is  the  shortest  that  has  been  observed,  to  between 
four  and  five  months  ;  but  commonly,  in  untreated  cases,  it  lasts  about  six 
weeks.  At  the  end  of  this  time  it  is  believed  that  the  organism  has  be- 
come so  saturated  with  the  poison,  which  has  been  multiplying  within  it, 
that  an  explosion  necessarily  takes  place  in  the  way  of  general  symptoms, 
in  order  to  enable  the  blood  to  get  rid  of  some  of  the  unnatural  material 
it  contains. 

During  the  second  incubation  the  general  health  may  appear  flourish- 
ing, but  generally  the  patient  commences  to  get  pale  and  languid,  or 
more  or  less  depressed.  His  red  cells  diminish  in  quantity  in  the  blood, 
and  the  number  of  white  cells  increases.  The  appetite  is  apt  to  falter  and 
the  digestion  to  become  less  vigorous,  yet  there  is  often  no  positive  fail- 
ure of  health  until  the  eruptions  appear,  and  sometimes  no  obvious  fail- 
ure even  then.  The  patient  may  be  about  his  affairs  as  usual,  carrying 
a  chancre,  which  does  not  disturb  him  greatly,  feeling  in  good  health,  and 
yet  covered  with  a  roseola,  which  his  physician  discovers  for  him,  of  which 
he  himself  has  been  totally  unconscious,  and  which  has  not  been  ushered 
in  by  any  fever,  or  by  any  subjective  symptom  of  which  the  patient  has 
taken  note. 

SYPHILITIC    FEVER. 

All  descriptions  of  syphilis,  from  the  earliest  times,  have  referred  to 
fever  as  being  one  of  the  accompaniments  of  the  disease  ;  but  no  thor- 
ough knowledge  of  it  was  obtained  by  the  profession  until  the  laborious 
investigations  of  Giintz,  with  the  aid  of  the  thermometer,  had  established 
its  finer  details.  In  1873, '  Guntz's  results,  many  of  which  had  appeared 
in  different  articles  in  medical  journals  during  the  previous  ten  years, 
were  put  into  book  form,  and  this  volume  is  still  the  highest  authority 
upon  syphilitic  fever. 

The  fever  of  syphilis  has  been  compared  to  that  of  the  exanthemata. 
It  comes  upon  the  patient  unawares  during  the  period  of  second  incuba- 
tion, and  precedes  the  outbreak  of  the  first  eruption.  It  is  this  fever  to 
which  the  name  syphilitic  is  given.  Other  febrile  states  due  to  syphilitic 
lesions  are  not,  as  a  rule,  called  by  this  name.  With  a  true  chancre  some- 
times a  bubo  suppurates,  and  the  formation  may  be  attended  by  a  rise  of 
temperature  ;  but  this  would  not  be  syphilitic  fever.  Again,  in  all  the 
cachectic  conditions  of  tertiary  syphilis,  with  the  bone  and  visceral  lesions 
in  brain  syphilis,  etc.,  a  rise  in  temperature  is  one  of  the  clinical  features 
of  the  affection  ;  yet  this  is  not  syphilitic  fever. 

The  true  syphilitic  fever,  according  to  Giintz,  generally  comes  on  at 
about  two  months  after  infection — sometimes  as  late  as  three  months. 
This  would  place  its  date  of  appearance,  in  average  cases,  during  the  early 
part  of  the  second  month  after  the  appearance  of  the  chancre,  and  clini- 
cally this  is  the  date  at  which  it  is  well  to  be  on  the  watch  for  fever,  so 
as  to  be  warned  of  the  first  eruption,  which  is  about  to  appear.  The  type 
of  the  fever  may  be  continued,  remittent,  or  intermittent.  It  may  consist 
of  a  single  short  outburst,  or  may  last  for  days.  Occasionally,  it  closely 
resembles  tertian  ague  ;  and  sometimes,  when  intense  and  accompanying 

1 J.  F.  Giintz  •  Das  syphilitiscbe  Fieber.     Leipzig,  1873 


102  THE    VENEREAL   DISEASES. 

syphilitic  pains  in  the  muscles  and  joints,  it  is  indistinguishable  from  a 
mild  attack  of  inflammatory  rheumatism.  More  rarely  still,  it  is  accom- 
panied bv  great  prostration,  attended  by  headache  and  epistaxis,  and  as- 
sumes a  type  suggestive  of  typhoid  fever. 

Its  occurrence  is  by  no  means  uniform.  Giintz  believes  it  to  be  found 
in  only  twenty  per  cent,  of  all  cases.  Lancereaux  puts  it  at  sixty-six  per 
cent.  Fournier  believes  it  more  common  in  women.  We  may,  therefore, 
conclude  that  in  not  more  than  half  the  cases  is  it  to  be  expected  at  all. 
Clinically,  it  is  certainly  very  rarely  of  any  importance.  If  it  is  looked 
for  by  aid  of  the  thermometer,  it  will  be  often  found  ;  otherwise  it  will 
rarely  be  thought  of  either  by  the  patient  or  physician,  excepting  in  a 
minoritv  of  cases  where  the  prostration  is  great,  or  the  range  of  tempera- 
ture high. 

The  thermometer  rarely  marks  higher  than  102°  Fahrenheit  in  syphili- 
tic fever  ;  104°  has  been  pretty  generally  considered  to  be  a  point  above 
which  it  does  not  go.  I  am  only  aware  of  one  case,  reported  by  Bremer, 
in  which  this  limit  was  exceeded. 

The  symptoms  attending  the  fever  are  very  variable.  Anaemia  may  be 
quite  marked,  the  pallor  being  due  to  the  well-known  diminution  in  the 
liremoglobulin  of  the  blood,  first  pointed  out  (1844)  by  Grassi.  General 
depression  and  a  feeling  of  being  sick  is  a  common  complaint.  Pains  in 
the  bones,  in  the  joints,  under  the  sternum,  in  the  side  and  back,  in  the 
head,  all  of  them  worse  at  night,  are  apt  to  be  complained  of.  The  night 
headache  is  pretty  constant  and  sometimes  frightfully  severe,  the  pain 
coming  on  at  a  stated  hour,  and  yielding  at  a  stated  hour,  often  with  great 
regularity.  The  joint  pains  may  also  get  worse  at  night.  They  generally 
do  so,  but  not  to  the  same  extent  as  the  head  pains.  Sometimes  the  joints 
and  the  bursne  under  the  insertions  of  the  tendons  (particularly  at  the  el- 
bow and  knee)  become  the  seat  of  effusion,  and  are  very  sensitive  to  hand- 
ling. The  patient's  skin  is  bathed  more  or  less  profusely  in  perspiration, 
the  urine  is  acid  and  full  of  urates.  In  such  a  case,  acute  articular  rheu- 
matism is  closely  simulated.  I  have  observed  one  very  well-marked  case 
of  this  character  in  the  Charity  Hospital,  which  yielded  a  prompt  response 
to  mercury. 

Where  the  fever  runs  high  and  an  eruption  is  coming  out,  the  mistake 
of  confounding  syphilis  with  measles,  or  even  with  small-pox,  has  been 
made. 

There  may  be  enough  shortness  of  breath  and  quickness  of  pulse  to 
suggest  lung  disease.  The  stomach  symptoms  may  be  the  most  promi- 
nent. An  unwonted  excess  in  the  appetite  may  be  a  feature  of  early 
syphilis  (boulimia).  Fournier  found  it  to  be  not  very  uncommon  in 
women.  Nausea  and  inappetence  are  more  common,  with  occasionally 
light  diarrhoea. 

Jaundice  may  come  on  with  syphilitic  fever,  due  to  catarrh  of  the  bile- 
ducts,  from  engorgement  of  the  mucous  membrane,  or  pressure  upon  the 
ducts  by  enlarged  glands  (Lancereaux). 

Pressure  upon  the  lower  third  of  the  sternum  will  sometimes  evoke  a 
pain  not  otherwise  complained  of,  and  the  anaemia  may  be  great  enough 
to  give  the  soft,  blowing  character  to  the  first  sound  of  the  heart. 

Syphilitic  fever  usually  disappears  soon  after  the  general  eruption 
comes  out.  Its  own  special  features  are  so  varied  that  its  diagnosis  de- 
pends upon  the  previous  (or  actual)  existence  of  a  chancre  and  the  pres- 
ence of  evidences  of  general  syphilis,  such  as  the  falling  of  the  hair,  an 
eruption,  epitrochlear  and  post-cervical  ganglionic  engorgement.  Its 


SYPHILIS.  103 

treatment  is  that  of  general  syphilis  in  the  early  months.  Syphilitic  head- 
ache, the  most  serious  symptom  of  this  fever,  may  sometimes  be  controlled 
by  minute  doses  of  mercury  repeated  at  short  intervals,  as  suggested  by 
Trousseau.  One-twelfth  of  a  grain  of  calomel  every  one  or  two  hours, 
for  twenty-four  hours,  will  sometimes  overcome  it.  It  is  not  well  to  con- 
tinue these  minute,  but  often  repeated  doses  for  any  length  of  time,  since 
mercury  given  in  this  way  is  apt  to  excite  speedy  salivation  in  certain 
people. 


SYMPTOMS    ATTENDING   THE    BEGINNING   OF   GENERAL   SYPHILIS. 

During  syphilitic  fever,  or  at  the  beginning  of  general  syphilis,  when 
there  is  no  fever,  it  is  common  to  observe  certain  symptoms.  These  need 
not  be  fully  described  here,  since  repetition  is  to  be  avoided.  They  may 
be  found  under  their  appropriate  heads;  but,  before  going  into  syphilis  as 
affecting  the  tissues  and  organs,  it  is  well  to  mention  these  symptoms,  if 
only  by  name. 

With  the  scabs  in  the  hair  of  early  syphilis,  and  the  mottling  of  the 
skin,  the  ganglionic  pleiad  in  the  groin  still  remaining,  and  perhaps  the 
chancre  being  still  raw,  we  generally  find  that  one  or  both  epitrochlear 
glands  are  indolently  indurated,  resembling  the  glands  in  the  groin,  and 
that  certain  glands  in  the  posterior  chain  of  the  posterior  cervical  glands 
are  similarly  affected.  The  glands  most  characteristic  among  these  are 
those  lying  on  the  occipital  bone  on  either  side  of  the  nucha.  These 
glands,  as  well  as  the  glands  in  the  groin,  generally  disappear,  with  or 
without  treatment,  as  the  disease  advances,  and  it  is  not  well  to  depend 
upon  them  to  corroborate  syphilis  after  the  first  few  months. 

Another  symptom  is  a  generalized  falling  of  the  hair  (syphilitic  alo- 
pecia). The  hair  thins  out  over  the  whole  scalp,  does  not  fall  in  patches, 
and  with  this  there  may  generally  be  noted  a  tendency  to  a  fall  of  hair 
from  the  beard  and  eyebrows,  and  more  or  less  from  the  whole  body  in 
severe  cases.  This  alopecia,  however,  is  often  confined  to  the  scalp. 
When  the  hair  falls  late  in  syphilis,  if  the  falling  out  of  hair  is  general, 
it  is  due  to  cachexia;  if  it  is  local,  it  is  due  to  a  local  physical  lesion  (ulcer) 
involving  the  papillae,  and  the  hair  does  not  generally  return  when  the 
disease  gets  well,  as  it  does  after  the  alopecia  of  early  syphilis. 

The  throat  symptoms — erythema,  mucous  patches — will  be  described 
later.  They  are  very  characteristic,  and  should  always  be  looked  for  in 
the  outbreak  of  general  syphilis. 

Certain  analgesias  of  early  syphilis  have  been  much  spoken  of  since 
Fournier's  description  of  them  as  they  occur  in  women  early  in  syphilis. 
Inability  to  distinguish  heat  from  cold,  anaesthesia  of  certain  limited  areas 
of  skin,  analgesias  due  to  early  syphilis,  have  been  described  mostly  as 
found  in  women.  These  symptoms  do  not  seem  to  stay  long;  they  are 
rarely  observed  in  ordinary  practice,  and  do  not  call  for  any  modification 
in  the  general  treatment.  The  backs  of  the  hands  and  wrists  seem  to 
suffer  more  often  than  other  parts.  Fournier  has  described  this  malady 
in  his  admirable  treatise  on  syphilis,  studied  especially  in  its  relation  to 
women,  Paris,  1873. 


CHAPTER  VI. 

THE   GEXERAL   TBEATMEKT    OF   SYPHILIS. 

Syphilis  a  self  limiting  Malady. — It  gets  well  under  all  Treatments  sometimes,  but 
yields  the  best  Results  to  small  Doses  of  Mercury  continued  for  a  long  Time. — 
Syphilization  and  Tartarization. — The  Hot  Springs  of  Arkanr-as. — Preventive 
Treatment  of  Syphilis. — Excision  of  Syphilitic  Chancre. — The  Hygienic  Treat- 
ment of  Syphilis. — The  Hygiene  of  the  Mouth. — Hygiene  of  the  Anus  and  of  the 
Genitals. — Hygienic  Medication. — Kumyss. — Specific  Treatment  of  Syphilis. — Gen- 
eral Consideration  of  the  Value  of  Mercury  and  the  Different  Kinds  of  Mercurial 
Treatment. — Salivation. — Time  at  which  the  General  Treatment  of  Syphilis 
should  be  commenced. — Detail  of  the  Tonic  Treatment  of  Syphilis  by  Mercury. 
— The  Time  at  which  a  Tonic  Course  of  the  Mercurial  Specific  may  be  stopped. 

SYPHILIS  is  naturally  a  self -limiting  malady,  and  its  general  treatment 
may  be,  and  often  is,  left  entirely  to  nature.  Many  a  woman,  and  occa- 
sionally a  man,  gets  syphilis  without  knowing  it,  and  runs  through  the 
disease  into  health  without  any  specific  treatment  at  all.  Indeed,  it  may 
perhaps  be  justly  doubted  whether  treatment  of  any  kind  can  shorten  the 
duration  of  syphilis  at  all,  for  the  disease  will,  and  it  does,  crop  out  at  re- 
mote dates  after  any  and  all  kinds  of  treatment  (more  often  after  certain 
kinds  of  treatment  than  after  others,  I  believe),  and  there  is  no  positive  and 
certain  test  which  can  be  applied  to  a  person  to  determine  whether  he  is, 
after  treatment,  free  from  the  disease  or  not.  The  cauterisatio  provoca- 
toria  of  Tarnowsky  (p.  78),  has  been  but  a  short  time  before  the  profes- 
sion, but  its  pretensions  have  already  been  assailed  by  Auspitz  and  Kaposi. 

There  is  no  doubt  whatsoever  that  certain  drugs  restrain  the  manifes- 
tations of  syphilis  and  cure  the  symptoms.  Among  these  the  different 
preparations  of  mercury  and  of  iodine  undoubtedly  hold  the  first  rank; 
but  the  opponents  of  the  internal  use  of  mercury  claim  that,  by  curing 
the  earlier  symptoms,  the  disease  proper  is  only  being  suppressed,  that  its 
total  duration  is  thereby  prolonged,  and  its  later  symptoms  rendered 
more  obstinate  and  more  destructive.  This  assumption,  however,  is  the  re- 
sult of  the  heat  of  controversy  more  than  of  any  calm  recognition  of  facts. 

AN  ho  shall  say,  in  a  given  case,  how  long  syphilis  is  to  last  ?  There  is 
no  certain  and  reliable  standard  by  which  the  disease  may  be  judged  or 
the  quality  of  its  virulence  predicated.  This  matter  has  already  been  dis- 
cussed in  the  section  on  prognosis  (p.  79),  and  need  not  be  reviewed  here; 
but  certain  it  is  that  there  is  an  unknown  element  in  syphilis  which  alone 
can  explain  the  endless  irregularity  of  its  forms  and  the  picturesque  vari- 
ety of  its  symptoms. 

One  fact  about  syphilis  is  well  known:  it  has  symptoms,  and  certain 
drugs  will  keep  down  those  symptoms;  and  it  is  as  wise  and  as  just  to  say 
that  the  quinine  which  breaks  tertian  ague  only  prolongs  the  disease  by 
suppressing  the  symptoms  (and  some  do  assert  this),  as  it  is  to  hold  that 
mercury  prolongs  syphilis  by  keeping  symptoms  in  check. 


SYPHILIS.  105 

Moreover,  the  use  of  mercury  has  been  shamefully  abused  in  times 
past.  Crusades  have  been  preached  against  the  drug  by  valiant  cham- 
pions of  other  and  seemingly  more  simple  and  more  natural  methods, 
yet  always,  century  after  century,  the  profession  clings  to  mercury;  and 
to-day  it  heads  the  list  of  specifics,  as  being  the  most  efficient  for  good  of 
ail  known  drugs,  in  the  writings  of  a  great  majority  of  the  recognized 
authorities  upon  syphilis.  The  only  question  is  how  to  use  mercury  so 
that  it  shall  inflict  the  greatest  possible  harm  upon  the  disease  without 
injuring  the  patient.  A  solution  to  this  problem  is  what  is  required.  I 
have  done  what  I  could  toward  solving  it — with  what  effect,  time  must 
show. 

It  is  not  within  the  province  of  this  volume  to  enter  into  a  study  of 
the  history  of  the  treatment  of  syphilis.  Probably  all  known  drugs  have 
been  at  one  time  or  other  tried  against  it;  but  they  have  disappeared 
one  after  another.  It  is  generally  a  new  vegetable  product  which  claims 
the  power  of  eradicating  syphilis.  Sarsaparilla  is  still  held  in  high  es- 
teem in  some  quarters,  and  guaiac  in  others.  Cundurango  bark  came  lately 
upon  the  scene,  but  promptly  disappeared.  I  believe  that  tuyuja  is  the 
present  novelty — destined,  doubtless,  to  share  the  fate  of  its  predecessors. 
Nearly  all  the  natural  mineral  springs,  especially  the  sulphur  springs, 
possess,  it  is  claimed,  the  power  of  eradicating  syphilis,  or  rather  that  mys- 
terious entity  known  as  "  the  effects  of  syphilis  and  of  mercury,"  from  the 
sj'stem;  and  for  some  springs  actual  specific  powers  over  the  disease  are 
assumed,  such  as  the  Hot  Springs  of  Arkansas,  the  Paso  Robles  Springs  of 
Colorado,  the  springs  of  San  Diego  in  Cuba,  and  others. 

Finally,  all  sorts  of  cures  abound:  water  cures,  dry  cures,  sweating 
cures;  cures  by  the  grace  of  God  (Diday) — that  is,  where  nothing  is  done 
in  mild  cases  beyond  what  is  suggested  by  ordinary  hygiene,  the  disease 
being  left  to  run  itself  out  by  nature;  cures  by  syphilization  and  by  tar- 
tarization;  and  finally,  by  drugs,  cathartics,  diuretics,  sudorifics,  tonics, 
mercury,  iodine,  etc. 

When  so  many  methods  are  strongly  advocated,  it  seems  fair  to  sup- 
pose that  the  disease  in  question  is  incurable;  but,  on  the  contrary,  pa- 
tients get  well,  or  seemingly  well,  under  all  these  methods  and  under  all 
systems  of  treatment.  The  reason  of  this  seems  to  me  to  be  that  the 
disease  is  self-limiting  and  symptoms  cease  to  appear,  in  a  majority  of 
cases,  in  the  long  run,  with  treatment,  without  treatment,  sometimes  de- 
spite treatment. 

The  aim  of  a  rational  treatment,  therefore,  must  be:  to  suppress  symp- 
toms and  prevent  them  from  doing  harm  during  their  existence;  to  con- 
trol symptoms  and  prevent  relapse  without  harming  the  patient  in  any 
way;  and  so  to  manage  the  disease  that  it  may  not  be  contagious  dur- 
ing its  existence  (by  keeping  down  such  symptoms  as  yield  contagious  se- 
cretions), that  the  patient  may  be  made  able  to  marry  as  soon  as  possi- 
ble and  to  produce  healthy  offspring,  and  that  the  symptoms  of  the  disease 
during  their  progress  shall  be  restrained  from  leaving  unsightly  scars  or 
damaging  the  structure  of  tissues  or  organs  during  their  existence. 

These  ends  may  be  more  certainly  attained  by  the  judicious  use  of  the 
preparations  of  mercury  and  iodine  than  by  any  other  means;  and  this  is 
the  reason  why  these  drugs  hold  their  place  in  medicine  as  anti-syphilitic 
specifics,  notwithstanding  the  fact  that  the  disease  goes  on  and  runs  its 
full  course  in  spite  of  their  use,  and  notwithstanding  the  fact  that  much 
harm  has  doubtless  been  done  with  the  drugs  by  their  unskilful  use,  and 
that  mercury  has  many  powerful  enemies  who  constantly  cry  out  against  it. 


106  THE    VENEREAL   DISEASES. 

Of  late,  two  German  authorities,  whose  high  position  renders  their 
verdict  worthy  of  respect — Sigmund  and  Zeissl — have  declared  themselves 
rather  in  favor  of  Diday's  way  of  regarding  syphilis. 

Sigmund  '  thinks  that  many  cases  of  syphilis  do  better  without  than 
with  general  treatment.  He  even  goes  so  far  as  to  say  that  general  treat- 
ment sometimes  does  harm.  He  thinks  that  forty  per  centum  of  untreated 
cases  have  such  light  eruptive  outbreaks  that  the  patients  do  not  detect 
their  secondary  symptoms  at  all,  while  ten  per  cent,  of  the  cases  having 
obvious  symptoms  get  well  promptly  by  the  use  of  local  measures  alone. 
Sigmund  thinks,  therefore,  that  treatment  should  not  be  commenced  until 
secondary  symptoms  appear — and  not  then,  unless  the  symptoms  threaten 
to  become  serious. 

The  only  deduction  to  be  drawn  from  the  above  conclusions  of  Sig- 
mund is,  that  he  is  fortunate  in  treating  an  exceptionally  high  average 
of  very  mild  cases  of  syphilis.  The  fact  that  so  conservative  an  authority 
still  uses  meroury  for  severe  cases  proves  that  he  does  not  consider  this 
drug  harmful  when  judiciously  employed,  and  shows  that  he,  with  most 
other  modern  authorities,  are  giving  up  the  careless  and  lavish  routine 
use  of  mercury.  They  are  using  less  mercury,  but  are  still  using  it  as  a 
specific. 

Zeissl, "  in  a  more  studied  essay,  giving  his  present  views  about  the  treat- 
ment of  syphilis,  states  that  by  observing  the  evolution  of  syphilis,  under 
the  expectant  treatment,  he  learned  that  the  malady  was  atypical,  seem- 
ing to  depend,  for  the  length  of  time  it  lasted  and  the  severity  of  its  symp- 
toms, more  upon  the  personal  physical  individuality  of  the  patient  than 
upon  the  treatment  to  which  he  was  subjected. 

Therefore  Zeissl  adopts  the  expectant  treatment  for  a  time.  He  allows 
the  disease  time  to  bloom — to  ripen,  as  it  were.  If  the  early  eruptions  go 
down  with  reasonable  promptness,  he  uses  no  mercury.  If  they  hesitate 
to  disappear,  he  tries  the  iodides,  and  only  in  severe  and  obstinate  cases 
does  he  have  recourse  to  mercurials  at  all. 

In  this  way  he  thinks  that  the  total  duration  of  the  disease  is  lessened, 
and  ultimate  serious  relapse  rendered  less  probable.  He  believes  that  the 
disease  blows  itself  out,  as  it  were,  if  allowed  free  play  in  its  earlier  stages. 
In  all  severe  cases,  however,  and  in  all  obstinate  ones,  he  still  depends 
upon  the  faithful  services  of  friendly  mercury. 

In  short,  he  too  is  giving  less  of  the  drug.  From  all  sides  testimony 
is  coming  in,  in  one  way  or  another,  favoring  a  reduction  in  the  amount 
of  mercury  used  in  the  treatment  of  syphilis. 

Some  of  the  symptoms  of  syphilis  disappear  under  the  influence  of 
intercurrent  disorders.  Thus,  Mauriac  has  shown,8  in  studying  the  cuta- 
neous symptoms  of  syphilis,  that  erysipelas  occurring  upon  the  surface 
of  a  person  with  a  syphilide  acts  generally  as  well  as  locally,  portions  of 
the  syphilitic  eruption  distant  from  the  area  occupied  by  the  erysipelas 
getting  well  just  as  those  spots  do  over  which  the  erysipelas  passes;  but 
with  this  difference,  that  the  more  distant  the  situation  of  the  spots  from 
the  erysipelatous  patch  the  less  promptly  do  they  get  well. 

This  is  not  more  strange  than  the  disappearance  of  cutaneous  lesions, 
not  syphilitic,  on  the  advent  of  some  internal  malady — tubercular  menin- 
gitis, typhoid  fever,  and  others. 

1  Wiener  med.  Wochenschrift,  No.  10,  1879. 

*  Wiener  med.  Zeitung,  Nos.  1,  2,  3,  and  4,  1879. 

3  Etude  clinique  sur  1'influence  curative  de  1'erysipele  dans  la  syphilis.  Paris,  1873. 


SYPHILIS.  107 

Syphilization  and  tartarization,  as  remedies,  belong  apparently  to  this 
class.  By  these  methods  of  treatment  the  skin  is  constantly  and  repeat- 
edly irritated  up  to  the  point  of  suppuration  in  numerous  spots,  until 
finally  no  more  suppuration  can  be  produced  by  the  irritants  supplied — 
chancroidal  pus,  or  that  of  irritated  chancres,  etc.  Under  this  treatment, 
eruptions  very  naturally  disappear,  and  thus  a  cure  of  syphilis  may  be 
claimed.  But  syphilization  can  never  be  generally  popular.  It  produces 
far  more  numerous  and  unsightly  scars  than  the  disease  itself,  and,  rather 
than  use  it,  most  people  would  prefer  to  let  the  malady  run  its  course 
until  the  third  stage,  and  then  use  the  iodide  of  potassium  for  the  treat- 
ment of  gummata  and  threatened  disease  of  internal  organs,  just  as  the 
syphilizers  themselves  do. 


THE  HOT  SPRINGS  OF  ARKANSAS. 

These  springs  have  of  late  become  very  popular,  especially  among  the 
people,  and  some  estimate  of  their  value  must  be  given.  I  have  not  had 
an  opportunity  to  visit  the  springs  personally,  but  I  have  had  charge  of 
numbers  of  patients  in  all  stages  of  syphilis,  who  have  been  to  the  springs 
either  before  or  during  the  term  of  my  treatment,  and  have  remained 
there  for  periods  varying  from  a  few  days  up  to  several  months.  I  feel, 
therefore,  reasonably  familiar  with  the  methods  employed  (as  a  rule) 
at  the  springs,  and  capable  of  judging  the  results,  on  account  of  having 
watched  many  patients  since  their  return. 

I  have  been  unable  to  ascertain  that  there  is  any  quality  in  the  water 
to  which  the  result  claimed  to  be  attained  may  be  ascribed,  excepting 
the  heat.  The  water  is  certainly  quite  poor  in  mineral  ingredients,  while 
its  alleged  magnetic  qualities  are  imponderable. 

When  a  patient  goes  to  the  hot  springs  in  any  stage  of  syphilis,  he  is 
apt  to  be  mercurialized  to  excess  by  the  inunction  of  mercurial  ointment. 
There  are  excellent  medical  men  at  the  springs,  who  use  mercury  judi- 
ciously ;  but,  unfortunately,  the  fame  of  the  place  attracts  some  physi- 
cians who  make  use  of  the  supposed  virtues  of  the  waters  to  shield  their 
own  incompetence,  and  the  credulous  patient  suffers.  In  directing  pa- 
tients to  the  springs,  in  the  cachectic  stage  of  the  disease — for  example, 
where  change  is  of  great  value  to  the  patient  he  should  be  regularly  con- 
signed to  a  reputable  physician,  or  his  trip  is  apt  to  do  him  but  little,  if 
any  good — possibly,  to  result  in  harm. 

I  believe,  however,  that  all  the  physicians  at  the  springs,  even  the  very 
best,  use  mercury  by  inunction  or  otherwise,  in  connection  with  the 
baths,  thus  plainly  avowing  a  disbelief  in  those  specific  and  curative  pow- 
ers of  the  waters  over  syphilis  which  are  generally  ascribed  to  them  by 
popular  superstition.  Iodide  of  potassium  internally  is  also  used  in  large 
amounts  by  the  physicians  at  the  springs. 

I  have  found  that  patients  who  go  to  the  hot  springs  with  chancre,  or 
during  the  earlier  periods  of  syphilis,  do  not  prosper  any  more  rapidly 
than  if  they  had  remained  at  home,  and  the  longed-for  exemption  from 
relapse  after  a  six  weeks'  course  at  the  springs,  with  any  amount  of  inunc- 
tions, is  far  from  being  justified  by  the  result.  Relapse  follows  just  as 
certainly  as  after  the  same  amount  of  mercury  used  at  home  in  the  same 
way,  and  no  more,  and  no  less  certainly,  according  to  my  experience. 

Late  along  in  the  disease,  however — especially  if  the  patient  be  broken 
and  cachectic  ;  if  his  appetite  and  his  vitality  require  the  influence  of 


108  THE   VENEREAL   DISEASES. 

change  ;  when  he  fails,  perhaps,  to  respond  at  all  to  the  iodides,  and  mercu- 
rials, even  in  small  doses,  depress  him — then  is  the  time  to  send  the  pa- 
tient  to  the  hot  springs.  The  change  alone  is  likely  to  benefit  him,  and 
the  waters  certainly  do  seem  to  possess  a  tonic  power  over  these  cases, 
which  brings  them  up  sometimes  far  more  promptly  than  seems  possible  at 
home,  and  helps  to  cure  them  not  only  of  their  active  symptoms,  but  some- 
times to  restore  them  to  good  general  health. 

Patients  sent  to  the  hot  springs  in  the  later  stages  of  cachectic  syphi- 
lis, generally  return  improved  and  gratified  with  their  experience.  Those 
who  go  early  are  usually  disappointed,  and  their  disease  not  sensibly  modi- 
fied in  any  way. 

If  the  springs  are  to  retain  any  permanent  value,  it  is  well  that  the 
public  should  be  dispossessed  of  the  absurd  idea  with  which  it  is  now  so 
thoroughly  imbued,  that  the  waters  themselves  possess  specific  qualities, 
ami  have  the  power  to  drive  out  syphilis  completely,  and  prevent  relapse. 
The  springs  certainly  have  their  value,  but  it  is  not  this. 


PREVENTIVE   TREATMENT    OP   SYPHILIS. 

It  is  hardly  appropriate  in  this  volume  to  touch  upon  the  subject  of 
prostitution.  Prostitution  has  probably  existed  from  the  beginning  of 
time,  and  it  doubtless  will  continue  to  exist  until  the  end  of  time.  The 
puritanical  spirit  which  causes  men  to  ignore  this  fact  is  to  blame  for  a 
certain  amount  of  the  syphilis  now  present  in  the  world.  The  only  way 
apparently  to  put  any  check  upon  the  spread  of  syphilis  by  prostitution, 
is  to  legalize  the  latter  occupation,  and  to  subject  it  to  close  and  constant 
scrutiny  by  officers  responsible  to  the  State.  The  general  spread  of  in- 
telligence through  the  world  will  doubtless  bring  this  about  sooner  or 
later  ;  but,  until  then,  the  young  men  of  the  community,  and  through  them 
their  wives  and  their  children,  stand  in  constant  danger  of  the  disease. 
Reasoning  from  my  own  experience  in  a  large  city,  syphilis  is  greatly  on 
the  increase  among  the  higher  classes  of  the  community.  Very  many 
young  men  in  the  best  walks  of  life  get  poisoned  by  their  own  folly,  and 
carry  the  germ  of  disease  into  their  homes.  Perhaps,  as  is  said  now  to  be 
the  case  in  Portugal,  we  shall  some  day,  as  a  community,  become  so  sat- 
urated with  syphilis,  that  the  type  of  the  disease  will  become  very  mild, 
and  we  shall  not  consider  it  of  much  importance  ;  but  it  is  rather  revolting 
to  one's  feelings  to  take  this  view  of  the  case. 

Leaving  prostitution  out  of  the  question,  and  coming  more  directly 
to  the  prophylactic  treatment  of  syphilis,  it  may  be  asked,  having  been 
exposed  to  the  poison  of  syphilis,  may  the  disease  be  prevented  ?  This 
question  has,  as  yet,  no  answer  based  upon  well-observed  facts.  Cer- 
tainly, if  the  syphilitic  poison — the  secretion  of  chancre,  for  example — 
comes  only  into  contact  with  the  unbroken  integument,  it  may  be  washed 
away,  and  the  individual  remains  sound.  The  same  is  equally  true  for 
the  mucous  membranes.  Cases  of  mediate  contagion  (p.  75)  prove  this 
as  well  as  those  cases  in  which  two  healthy  men  have  had  intercourse 
on  the  same  evening  with  the  same  syphilitic  woman,  when  one  of  the 
men  escapes  infection,  while  the  other,  in  due  time,  has  chancre.  Such 
instances  have  been  observed  more  than  once.  I  have  such  a  case  among 
my  own  patients.  The  explanation  is  simple.  The  poison  deposited 
beneath  the  prepuce  in  one  case  finds  the  semi-mucous  membrane  sound, 
and  does  not  effect  an  immediate  communication  with  the  absorbents. 


SYPHILIS.  109 

It  remains  inert,  and  is  washed  or  rubbed  away  by  the  patient.  In  the 
other  case  an  abrasion  or  little  fissure  exists  in  the  surface  epithelium, 
the  poison  is  promptly  absorbed,  and  no  amount  of  washing  can  then 
save  the  patient  from  chancre,  which  will  come  on  after  the  proper  period 
of  incubation  has  passed.  Whether  the  poison  of  chancre  deposited 
upon  the  unbroken  epithelium,  either  of  the  skin  or  of  the  mucous  mem- 
brane, can  in  time,  if  retained  in  place,  work  its  way  through  the  epithe- 
lium by  a  corroding  process,  and  gain  access  to  the  absorbents,  is  not 
known. 

Now  comes  the  question — when  once  a  chancre  appears,  may  syphilis 
be  averted  ?  It  is  not  proven  that  it  can  be,  although  the  evidence  of 
some  investigators  goes  a  certain  distance  to  show  that  it  may  be.  The 
whole  question  is  at  present  involved  in  doubt,  and  is  now  the  subject  of 
active  inquiry  and  experiment  in  the  medical  world.  Much  difficulty  at- 
tends a  just  solution  of  the  problem,  particularly  at  this  day,  when  so 
much  confusion  exists  about  the  quality  of  the  poisons  of  chancre  and 
chancroid,  their  identity  or  otherwise;  and  because  investigators  still 
trust  to  that  single  fallacious  symptom — induration — and  base  their  prog- 
nosis of  syphilis  upon  this  alone,  seeming  to  disregard  the  value  of  con- 
frontation, and  apparently  forgetting  to  consider  the  varied  forms  of 
pseudo-chancre,  some  of  which  show  syphilitic  induration  in  its  most 
typical  form.  Such  a  pseudo-chancre,  of  course,  whether  cut  out  or  left 
alone,  will  not  be  followed  by  any  signs  of  early  syphilis. 

The  question  of  the  value  of  the  excision  of  chancres  need  not  be 
reopened  here;  it  has  already  been  discussed  at  p.  93.  It  is  simply  cer- 
tain that,  at  the  present  date,  no  positive  assurance  can  be  given  to  a 
patient  that,  if  his  chancre  be  cut  out,  he  will  escape  general  symptoms. 
When  the  chancre  is  suitably  situated — as,  for  instance,  upon  the  edge 
of  the  preputial  orifice,  or  elsewhere — in  such  position  that  it  may  be 
easily  and  thoroughly  extirpated,  there  is  no  harm  that  can  follow  cutting 
it  away;  but  it  should  be  removed  with  a  distinct  understanding  that  an 
intelligent  experiment  is  being  performed,  and  nothing  more,  and  that 
the  chances  are  against  success,  if  the  chancre  be  a  true  initial  lesion  of 
syphilis. 


THE    HYGIENIC    TREATMENT   OP   SYPHILIS. 

The  hygienic  surroundings  of  a  patient  influence  his  general  health, 
and  upon  the  maintenance  of  good  general  health  often  depends  the 
quality  of  the  syphilitic  symptoms  in  a  given  case.  This  remark  is  not 
absolutely  true — indeed,  probably,  no  remark  made  about  syphilis  is  abso- 
lutely true.  Some  old  men,  with  broken  vitality,  in  the  decline  of  life,  get 
syphilis,  and  have  it  in  the  very  mildest  form,  while  robust  youths  some- 
times sink  away  promptly  under  a  malignant  onset  of  the  disease.  The 
activity  of  the  poison  in  babyhood  is  well  known,  and  that,  too,  not  in 
cases  of  inherited  syphilis  alone.  Epidemics  of  vaccinal  syphilis  clearly 
prove  the  virulence  of  acquired  syphilis  in  the  infant.  Then  there  are 
apparently  certain  diathetic  or  constitutional  peculiarities  of  the  individ- 
ual, which  influence  the  quality  of  his  syphilitic  symptoms,  and  act  inde- 
pendently of  hygienic  surroundings  and  of  everything  else.  This  subject 
has  been  discussed  in  the  section  on  prognosis,  p.  79. 

Therefore  it  cannot  be  absolutely  said  that  hygiene,  when  good,  will 
make  syphilis  mild,  and  when  bad,  will  make  it  severe,  for  this  is  not  the 


HO  THE   VENEREAL   DISEASES. 

case.  It  is  possible,  however,  I  think,  to  make  the  following  assertion 
with  truth:  that,  other  things  being  equal,  the  better  the  hygiene  and 
dietetics,  the  more  creditably  will  the  patient  weather  the  storm,  and  the 
more  certainly  will  his  disease  get  well  without  materially  damaging  him. 
This  assertion,  of  course,  implies  that,  in  addition  to  his  hygiene  and 
dietetics,  the  patient  shall  make  use  of  intelligent  therapeutics. 

The  hygiene  of  syphilis  is  that  of  common  every-day  life.  We  no 
longer  confine  patients  to  their  beds  for  the  treatment  of  syphilis,  or 
even  to  the  house.  The  old  notion,  that  it  is  such  a  serious  matter  for  a 
patient  taking  mercury  to  catch  cold,  cannot  be  held  in  force.  Surely  it 
is  wiser  for  a  patient  taking  mercury  not  to  catch  cold,  because  the  cold 
'is  apt  to  upset  his  stomach  and  to  interfere  with  his  treatment;  but 
bevond  this  I  do  not  know  any  disadvantage  likely  to  arise  from  taking 
cold.  And  I  do  not  believe  that  a  patient  taking  mercury  in  a  mild, 
continuous  wav,  is  any  more  apt  to  catch  cold  upon  exposure,  than 
another  under  the  same  circumstances,  not  taking  mercury.  Mercury 
may  open  the  pores,  as  the  popular  notion  is,  for  all  that  is  known  to  the 
contrary.  Mercury  certainly  is  excreted  in  minute  amounts  by  the  skin, 
in  the  perspiration;  but  it  means  nothing  to  say  that  the  pores  are  open — 
they  undoubtedly  always  are  open.  Finally,  to  sum  up,  I  believe  that  a 
patient,  while  taking  a  mild,  continuous  course  of  mercury,  may  go  out 
in  the  cold,  the  rain,  and  the  storm,  exactly  in  the  same  way  as  if  he 
were  not  taking  the  drug.  Precautions  against  taking  cold  are  certainly 
desirable  in  syphilis,  as  they  are  in  any  other  general  depressing  malady. 

Moreover,  a  cold  taken  in  the  active  stage  of  syphilis  may  produce 
sore  throat,  and  this  sore  throat,  due  primarily  to  cold,  may  be  the  occa- 
sion of  a  local  outcrop  of  mucous  patches,  and  syphilitic  ulcers  in  the 
throat,  which  may  continue  long  and  greatly  annoy  the  patient,  as  well 
as  possibly  aggravate  his  disease  by  interfering  with  swallowing,  and 
therefore,  with  nutrition.  An  accidental  sore  throat  may  produce  syphili- 
tic symptoms  in  the  throat,  just  as  smoking  may.  and  just  as  a  blister 
placed  upon  the  skin,  or  a  sulphur-bath,  may  call  out  a  syphilitic  eruption 
upon  a  patient  whose  skin  until  then  has  remained  clear. 

Therefore  it  is  very  desirable  that  a  patient  in  the  active  stages  of 
syphilis  should  take  all  precautions  not  to  take  cold;  but  he  should  be 
made  to  understand,  that  his  cold,  if  he  gets  it,  is  his  own  fault,  and  not 
to  be  blamed  upon  the  mercury  he  is  taking.  Probably  the  best  precau- 
tions against  taking  cold  are  the  use  of  hair-mittens  every  morning  upon 
the  dry  skin  of  the  whole  body,  when  there  is  no  general  eruption;  soak- 
ing the  feet  upon  retiring  at  night,  in  cold  water,  washing  the  neck  and 
chest  in  cold  water  in  the  morning,  and  not  wrapping  up  the  throat 
tightly  while  out  of  doors, — as  well  as  the  avoidance  of  wet  feet  and 
drafts. 

Cleanliness  of  the  whole  surface  of  the  body  by  frequent  bathing  is 
very  desirable  during  the  whole  continuance  of  the  treatment  of  syphilis — 
warm  water  (not  too  hot),  toilet  soap,  and  a  soft  towel,  being  used.  Of 
exercise  and  air  the  patient  should  have  an  abundance.  The  function 
of  the  stomach  and  the  intestine  should  be  ministered  to  by  appropriate 
food,  and  regularity  as  strict  as  possible  should  be  observed  in  regard  to 
meal-times  and  the  hours  of  sleep. 

In  regard  to  the  kind  of  food  to  be  used,  no  special  restrictions  need 
be  put  upon  the  patient.  He  may  eat  what  he  chooses,  and  what  he 
knows  will  agree  with  him,  in  full  .quantity,  as  if  in  ordinary  health— 
a  plain,  mixed  diet  of  meat,  vegetables,  bread,  butter,  and  milk  being 


SYPHILIS.  Ill 

most  appropriate.  There  is  no  objection  to  the  use  of  wine  or  beer,  in 
moderation,  with  the  meals;  but  any  excess  in  alcohol  in  any  shape  is  ob- 
jectionable, and  drinking  between  meals  should  not  be  allowed. 

Under  certain  circumstances  the  regulation  of  food  becomes  very  im- 
portant, namely,  when  the  medicines  which  must  be  given  to  control 
important  symptoms  irritate  the  stomach  so  that  they  cannot  be  borne. 
The  mercurials  in  any  form,  in  some  cases  of  weak  digestion  and  irritable 
bowels,  cause  more  or  less  griping  and  colicky  pain,  and  the  iodides  often 
produce  nausea  and  disability  of  the  stomach.  The  mercury  may  be 
made  to  remain  quietly  in  the  intestine  by  the  aid  of  opium,  but  it  is  far 
better  to  accomplish  the  same  result,  if  possible,  by  means  of  a  change  of 
food. 

When,  therefore,  moderate  medication,  such  as  may  be  necessary  to 
keep  down  the  symptoms,  is  found  to  produce  pain  and  diarrhoea,  all 
fruit  and  green  vegetables  must  be  denied  the  patient.  He  should  take 
no  beer,  and  but  little  fluid  of  any  sort.  He  should  eat  stale  bread  and 
butter,  tender  meat,  rice  and  boiled  milk,  eggs  and  toast,  and  by  the  ex- 
ercise of  these  simple  precautions  he  will,  often  be  able  to  continue  his 
mercury  and  avoid  opium.  If  another  medicine  must  be  given,  it  is  well 
to  commence  with  gr.  x.  doses  of  the  subnitrate  of  bismuth;  and  if  this 
serves  to  comfort  the  intestine,  and  keep  pain  and  diarrhoea  in  check,  it 
certainly  is  simpler  and  less  apt  to  do  harm  than  opium.  Besides  these 
means,  it  may  sometimes  be  necessary  to  employ  opium  as  well;  but,  if 
the  opium  can  be  escaped,  it  is  to  the  patient's  advantage. 

The  same  general  precautions  in  regard  to  diet  may  be  employed 
when  the  iodides  disagree.  The  subcarbonate  of  bismuth  may  be  tried 
instead  of  the  subnitrate  in  these  cases. 

The  residence  of  the  patient  is  not  a  matter  of  much  importance,  if 
his  general  health  and  his  appetite  remain  fair,  and  his  symptoms  yield 
reasonable  obedience  to  the  medicines  employed.  Change  of  air,  how- 
ever, is  always  desirable  occasionally,  even  to  persons  in  ordinary  good 
health,  and  this  is  the  more  necessary  when  the  patient  is  laboring  under 
a  devitalizing  disease.  Therefore,  even  if  the  course  of  the  malady  leaves 
nothing  to  be  wished  for,  it  is  wise,  for  such  patients  as  can  afford  the 
time  and  the  money,  to  make  a  change  of  residence  for  a  certain  period 
of  time  each  year,  in  the  summer  if  they  live  in  town,  in  the  winter,  if 
their  home  is  rural. 

This  change  of  air  and  surroundings  becomes  a  matter  of  necessity  in 
some  cases,  particularly  in  the  later  periods  of  the  disease,  if  there  be  any 
tendency  to  cachexia.  Under  these  circumstances  medicines  sometimes  fail 
entirely  to  improve  the  general  or  the  local  symptoms,  while  a  change  of 
air,  even  with  a  cessation  of  medication,  will  yield  excellent  results.  I  have 
known  patients,  both  early  and  late  in  the  disease,  who  fail  to  respond  to 
medication  until  that  medication  has  been  supplemented  by  a  change  of 
air,  when  not  only  would  the  symptoms  promptly  mend,  but  the  tone  of  the 
stomach  would  improve,  and  medicines  which  could  not  be  taken  at  all 
without  interfering  with  digestion  could  be  borne  without  a  murmur. 
This  is  particularly  the  case  with  the  iodides. 

In  one  case  under  my  care  this  effect  was  strongly  marked.  The  pa- 
tient had  a  node  which  threatened  to  destroy  the  nasal  bones.  He  could 
not  take  the  iodides  without  having  his  stomach  totally  upset,  while  at 
the  same  time  the  iodides  produced  a  brilliant  crop  of  purpura  oa  each 
occasion  when  they  were  tried.  I  therefore  sent  the  patient  to  the 
country,  with  directions  to  continue  his  medicines  there.  A  few  days 


112  THE    VENEREAL    DISEASES. 

sufficed.  He  bore  the  drug  well,  his  purpura  disappeared,  his  stomach 
regained  its  tone,  the  node  in  his  nose  visibly  diminished  in  size.  He 
therefore  returned  to  the  city,  thinking  himself  safe;  but  a  few  days 
convinced  him  to  the  contrary:  his  stomach  again  refused  food,  his  pur- 
pura returned,  and  he  was  obliged  to  go  back  to  the  country,  and  to  re- 
main there  until  his  node  disappeared,  which  it  promptly  did. 

The  advantage  patients  in  the  cachectic  stage  of  syphilis  often  derive 
from  visits  to  springs,  or  to  cities  even,  for  the  purpose  of  consulting 
some  special  physician  about  their  disease,  is  no  doubt  sometimes  due  to 
the  improved  hygienic  effect  of  their  surroundings.  This  effect  in  Xew 
York  City  seems  to  last  about  six  weeks,  after  which  patients  become 
used  to  the  locality  and  fail  any  longer  to  improve  in  it — from  the  effect 
of  climate  alone.  How  long  this  improving  effect  of  change  lasts  in  other 
localities,  I  do  not  know. 

The  hygiene  of  the  mouth  is  of  the  first  importance  in  the  treat- 
ment of  syphilis.  It  is  desirable  to  give  mercury  and  to  avoid  salivation, 
and  the  condition  of  the  mouth  and  of  the  teeth  is  therefore  of  the  first 
importance.  Mouth  lesions  and  throat  lesions  form  some  of  the  most  ob- 
stinate features  of  the  disease,  and  these  lesions  are  less  apt  to  be  severe 
when  the  mouth  is  kept  clean  and  free  from  the  contact  of  irritants. 

At  the  very  beginning  of  syphilis,  therefore,  before  the  mercurial  course 
is  commenced,  the  patient  should  be  sent  to  a  dentist  to  have  his  teeth 
put  in  thorough  order.  All  the  tartar  should  be  carefully  scraped  away 
from  the  necks  of  the  teeth,  and  all  old  stumps  extracted,  and  sharp  pro- 
jecting angles  of  teeth  likely  to  come  into  contact  with  the  tongue  filed 
off.  The  patient  should  be  instructed  that  he  will  do  well  to  visit  the 
dentist  regularly  every  six  months  if  the  tartar  tends  to  reaccumulate 
quickly,  as  it  does  in  some  cases.  During  the  whole  of  the  treatment  a 
very  soft  tooth-brush  should  be  used,  for  the  stiff  bristles  of  a  hard  brush 
cut  and  injure  the  gums,  and  make  them  more  apt  to  become  irritated  un- 
der the  influence  of  mercury  than  if  a  soft  brush  be  used.  Any  tooth- 
wash  employed,  or  tooth-powder,  should  be  strongly  alkaline  and  a  little 
astringent.  A  good,  simple  tooth-wash  is  made  by  putting  half  a  tea- 
spoonful  or  more  of  bicarbonate  of  soda  into  a  glass  of  water,  and  adding 
a  teaspoonful  of  tincture  of  myrrh.  Ordinary  white  castile  soap  makes  a 
good  and  simple  tooth-paste,  and  the  mouth  may  be  washed  out  after- 
ward with  some  alum  and  water,  or  some  tincture  of  krameria  (  3  j.)  in 
aquae  gaultheria  (  §  iv.). 

By  keeping  the  teeth  in  order  and  the  mouth  clean  by  these  and  sim- 
ilar precautions,  mucous  patches  become  less  annoying  and  easier  to  man- 
age, and  the  effect  of  the  amount  of  mercury  given  can  be  more  closely 
watched,  since  one  is  not  apt  to  be  misinformed  as  to  the  cause,  should 
the  edges  of  the  gums  begin  to  grow  soft  and  tender. 

Smoking  should  be  absolutely  forbidden  during  the  first  year  at  least 
of  syphilis,  and  often  for  a  much  longer  period.  If  the  patient  will  per- 
sist in  smoking,  he  ought  to  be  made  to  do  so  at  his  own  risk,  and  should 
be  willing  to  pay  up  for  the  pleasure  of  his  smoking  by  the  pain  of  more 
or  less  sore  tongue  and  throat,  and  a  great  number  more  of  mucous 
patches  and  mouth  lesions  than  he  would  otherwise  have  had.  Chewing- 
tobacco  is  in  many  cases  even  worse  than  smoking.  It  is  well  also  for  the 
patient  to  avoid  much  highly  spiced  or  stimulating  food,  since  such 
things  also  help  to  keep  the  mouth  tender. 

A  pipe  is  a  dangerous  thing  for  a  patient  with  syphilis  to  use,  for  he 
runs  the  risk  of  infecting  any  friend  who  might  use  it,  the  secretions  of 


SYPHILIS.  113 

mucous  patches  and  syphilitic  ulcers  in  the  mouth  being  particularly  cou- 
tagious. 

The  hygiene  of  the  genitals  and  of  the  anus  is  also  very  impor- 
tant in  syphilitic  cases.  These  parts  in  both  sexes  should  be  kept  scrupu- 
lously clean  and  dry,  otherwise  mucous  patches  and  condylomata,  excori- 
ations and  ulcerations,  are  to  be  looked  for.  Should  there  be  any  ten- 
dency to  moisture  about  these  parts  externally,  they  may  be  dusted  with 
dry  powders,  lycopodium,  starch,  bismuth,  with  or  without  a  little  calo- 
mel. Moisture  beneath  the  prepuce  may  be  kept  in  check  by  the  inser- 
tion of  a  thin  layer  of  absorbent  cotton  or  of  prepared  lint  beneath  it, 
twice  a  day,  after  it  has  been  washed.  It  is  well,  in  all  cases,  if  possible, 
to  have  the  patient  wash  the  anus  with  soap  and  water  after  each  action 
of  the  bowels.  The  umbilicus,  also,  in  fat  people,  and  the  skin  under  the 
breasts,  in  fat  women,  require  frequent  washing,  drying,  and  dusting,  to 
preserve  the  parts  in  good  condition  during  the  eruptive  period. 


HYGIENIC    MEDICATION. 

All  such  medicines  as  are  used  in  syphilitic  cases,  for  the  purpose  of 
maintaining  the  general  health  or  regulating  the  functions,  come  more 
justly  under  the  head  of  hygiene  than  of  specific  medication. 

All  tonics  find  a  fair  field  for  their  exercise  in  syphilitic  subjects,  and 
do  good — not,  perhaps,  in  curing  the  disease,  but  by  holding  the  patient 
up  while  the  disease  works  out  its  periods.  The  effect  of  mercury,  when 
given  in  small  doses  for  a  long  or  for  a  short  time,  is  undoubtedly  tonic, 
as  I  have  shown;1  but  it  is  not  at  all  on  account  of  this  tonic  action  that 
mercury  given  in  minute  doses  eliminates  the  syphilitic  poison.  Other 
drugs  are  far  more  tonic  in  their  action,  but,  having  no  specific  power  over 
the  symptoms  of  syphilis,  they  directly  modify  the  disease  but  little,  if  at 
all.  The  only  advantage  I  have  ever  claimed  for  the  long-continued  use 
of  mercury  in  minute  doses  is  that,  while  acting  in  minute  doses  as  a  spe- 
cific, it  has  the  great  advantage  to  the  patient  of  being  at  the  same  time 
tonic. 

Now,  the  ordinary  tonics — such  as  the  long  list  of  vegetable  bitters,  the 
quinine  group,  iron,  and  analogous  drugs,  together  with  cod-liver  oil  and 
similar  blood-formers — all  of  these  serve  a  good  part  in  the  treatment  of 
syphilis,  just  as  other  hygienic  means  do.  If  employed  with  intelligence 
and  judiciously  changed,  they  in  a  measure  take  the  place  of  change  of 
air  and  selection  of  food,  in  those  cases  in  which  lack  of  money  will  not 
allow  the  patient  to  alter  his  food  or  to  get  a  change  of  air.  Cod-liver 
oil  is  a  particularly  useful  adjuvant  to  treatment  in  those  cases  in  which 
the  blood-making  powers  are  defective,  while  the  ability  to  digest  fat 
remains.  } 

In  persons  who  lack  blood,  yet  in  whom  the  stomach  refuses  to  accept 
or  to  assimilate  so  concentrated  a  food  as  cod-liver  oil,  an  excellent  sub- 
stitute is  found  in  kumyss. 

Kumyss,  long  known  and  extensively  used  in  Europe,  especially  in 
Russia,  is  fermented  milk.  In  different  countries  it  is  made  out  of  differ- 
ent kinds  of  milk — that  of  asses,  mares,  cows.  In  America,  I  believe 
cows'  milk  only  is  used.  This  milk -beer  is  not  unpleasant  to  the  taste. 
It  resembles  buttermilk  well  aerated  with  carbonic  acid,  more  than  any- 

1  The  Effect  of  Small  Doses  of  Mercury,  etc.    Am.  Journ.  Med.  Sci. ,  January,  1876. 


114  THE    VENEREAL    DISEASES. 

thino-  else.  It  is  exceedingly  light  to  the  stomach,  and  seems  not  only  to 
digest  itself  (by  the  lactic  acid  it  contains),  but  to  help  digest  other  food. 
It  constipates  little  or  not  at  all,  and  does  not,  generally,  produce  head- 
ache, as  milk  often  does.  It  may  be  taken  in  indefinite  quantities,  but  a 
pint  to  a  quart  a  day  is  enough  for  most  people.  It  is  an  excellent  rem- 
edy in  dyspeptic  conditions,  and  generally  agrees  with  a  weak  stomach, 
whether  the  latter  be  due  to  syphilis  or  to  other  cause.  Often,  where 
cod-liver  oil  cannot  be  taken,  and  milk  does  not  agree,  kumyss  comes  to 
the  rescue  and  helps  to  turn  the  scale  in  the  patient's  favor.  Kumyss  is, 
of  late  years,  extensively  manufactured  through  the  country,  and  may  be 
easily  obtained  in  our  larger  cities  of  the  East.  It  bears  transportation 
moderatelv  well,  but  must  be  kept  cold.  Its  management  is  rather  diffi- 
cult as  put  up  by  some  manufacturers,  on  account  of  the  amount  of  car- 
bonic acid  gas  which  it  contains.  I  generally  direct  that  a  champagne 
syphon  be  used  to  draw  it  from  the  bottle,  and  that  the  kumyss  be  taken 
as  a  beverage,  with  or  just  after  meals — one  or  two  claret-glasses  at  a 
meal,  according  to  the  patient's  fondness  for  it,  and  its  effect  upon  him. 
An  appetite  for  the  drink  is  generally  soon  acquired. 


SPECIFIC   TREATMENT    OF   SYPHILIS. 

The  specific  treatment  of  syphilis  is  a  treatment  of  the  disease  b}-  those 
drugs  which  are  known  commonly  to  control  the  symptoms  in  an  imme- 
diate manner.  These  drugs  are  many  of  the  preparations  of  mercury  and 
of  iodine.  The  latter  are  found  to  exercise  much  less  influence  over  the 
symptoms  of  early  syphilis  than  mercury  does;  but,  in  revenge,  they  pos- 
sess a  controlling  power  over  many  of  the  tertiary  manifestations  of  the 
disease,  particularly  over  those  dependent  upon  gummatous  deposit,  no 
matter  in  what  tissue  such  deposit  occurs. 

Mercury,  on  the  other  hand,  has  undoubted  value  in  all  stages  of 
syphilis  and  over  all  its  lesions,  but  less  control  over  gummatous  deposit 
than  over  other  lesions.  Indeed,  although  sometimes  it  will  (in  form  of 
fumigation)  influence  a  gummatous  lesion  (ulcer,  for  example)  more  pos- 
itively and  more  promptly  than  the  iodides,  yet,  as  a  rule,  it  cannot  be 
relied  upon  to  overcome  symptoms  due  to  gummatous  deposit.  The  io- 
dides, in  such  cases,  serve  an  excellent  part  to  supplement  the  action 
of  mercury  just  here  where  it  is  the  weakest.  In  treating  a  gumma,  the 
object  is  to  dissipate  the  deposit  as  promptly  as  possible,  so  as  to  save 
the  tissues  involved  from  damage  by  pressure,  or  by  disintegration  when 
they  are  included  in  the  gummatous  mass;  and  this  the  iodides  do  speed- 
ily if  vigorously  pushed  and  well  borne  by  the  stomach,  while  the  mercu- 
rials will  often  fail  to  do  it. 

The  iodides,  on  the  other  hand,  have  little  or  no  power  to  prevent 
relapse;  and,  when  they  have  done  all  their  work,  mercury  often  has  to 
be  called  in  to  endorse  the  cure  and  to  prevent  a  return  of  the  symptoms. 
Thus  the  two  specifics  support  each  other. 

These  facts  I  think  I  have  demonstrated  in  an  essay  on  the  "  Inter- 
nal Treatment  of  Syphilis,"  read  before  the  Medical  Congress  in  Phila- 
delphia, in  1876,  and  contained  in  the  printed  transactions  of  that  body. 
therefore  judge  it  to  be  unnecessary  to  reproduce  the  line  of  argument 
here. 

It  is  also  equally  foreign  to  a  book  of  this  character  to  go  deeply  into 
the  detail  of  scientific  work.  I  shall  therefore  say  little  or  nothing  about 


SYPHILIS.  115 

the  counting  of  blood-corpuscles,  and  the  steps  which  lead  directly  to  the 
conclusion  that  mercury  is  a  tonic  when  administered  in  minute  doses,  no 
matter  over  what  length  of  time  its  administration  may  be  continued. 
This  conclusion  I  believe  I  have  demonstrated  to  be  a  fact  in  the  essay 
already  alluded  to  upon  the  '•  Effect  of  Small  Doses  of  Mercury  in  Syphilis," 
which  appeared  in  the  January  number  of  the  American  Journal  of  Medi- 
cal Sciences,  in  1876.  Those  interested  in  following  the  study  of  the 
blood  and  the  course  of  argument  derived  from  other  facts  which  prove 
that  mercury  in  minute  doses  long  continued  is  a  tonic,  while  in  large 
doses  it  is  atonic,  diminishing  the  number  of  the  red  cells  in  the  blood, 
are  referred  to  the  two  papers  in  question.  There  I  think  it  will  be  found 
to  be  demonstrated  that  mercury,  properly  used  for  a  number  of  years  in 
Succession,  cannot  do  any  harm  to  a  patient,  while  it  certainly,  in  most 
cases,  controls  his  symptoms  in  a  greater  or  less  degree.  I  have  but  to 
add  here  that  the  years  which  have  passed  since  the  appearance  of  those 
papers  have  only  served  to  strengthen  my  convictions  in  the  correctness 
of  the  conclusions  there  reached.  The  only  modification  I  have  made 
has  been  to  somewhat  diminish  the  dose  of  mercury  for  continuous  use, 
making  the  tonic  dose  more  often  one-third  rather  than  one-half  of  the 
full  dose;  and,  in  revenge,  I  am  inclined  to  extend  the  treatment  into  the 
fourth  year  in  a  majority  of  instances,  where  such  prolonged  treatment  is 
practicable. 

Relapses  certainly  do  occur  after  this  time,  but,  in  my  experience,  they 
have  been  invariably  mild,  and  have  come  readily  under  the  control  of 
specific  medication.  Mouth  symptoms  during  this  course  are  generally 
more  obstinate  than  any  others,  but  I  look  upon  the  little  scaly  patches 
upon  the  tongue  and  lips  more  as  an  evidence  of  local  irritation,  in  a  per- 
son once  syphilitic,  than  anything  else,  and  I  am  now  in  the  habit  of  treat- 
ing them  locally  in  many  cases,  without  making  any  change  in  the  inter- 
nal dose  which  the  patient  may  be  taking  at  the  time. 

The  coup  sur  coup  plan  of  giving  mercury  I  have  never  followed  up, 
being  satisfied,  from  the  results  in  the  way  of  relapses  I  have  seen  in  pa- 
tients who  have  so  taken  the  drug  at  competent  hands,  that  this  form  of 
treatment  leaves  much  to  be  desired.  The  plan  known  as  Fournier's  treat- 
ment, which  consists  in  the  interrupted  use  of  mercury  in  mild  form  (a 
gentle  coup  sur  coup  method),  with  stated  definite  intervals  in  which  no 
treatment  is  used,  seems  to  me  to  rest  upon  no  foundation  stronger  than 
theory,  since  syphilis,  a  malady  of  interruptions  undoubtedly,  has  its  in- 
terruptions at  indefinite  and  irregular  intervals.  Notwithstanding  that 
intervals  of  latency  in  the  malady  exist,  periods  of  apparent  immunity 
from  the  disease,  yet  there  is  nothing  to  prove  that  the  patient  is  free 
from  the  poison  during  those  intervals,  but  everything  to  show  that  he  is 
still  suffering.  The  cauterisatio  provocatoria  of  Tarnowsky  (p.  78)  is 
founded  upon  this  assumption.  A  blister  or  a  local  irritant  (vaccination) 
will  sometimes  make  latent  syphilis  active — a  woman  seemingly  perfectly 
healthy  will  often  produce  a  syphilitic  child.  What  conclusion  can  there- 
fore be  reached  except  that  syphilis  is  a  mild,  continuous  disease,  with 
periods  of  passive  latency  and  periods  of  active  outbreak  ;  and  what 
treatment,  therefore,  recommends  itself  more  to  common  sense  than  a  mild, 
long-continued,  uninterrupted  treatment  by  a  specific  known  to  have 
power  over  the  symptoms,  with  an  increase  in  the  quantity  of  that  speci- 
fic during  the  periods  of  outbreak  ? 

And  this  becomes  especially  apparent  when  it  can  be  shown,  as  I  think 
I  have  done,  that  the  continuous  use  of  the  mild  specific  acts  as  a  general 


116  THE    VENEREAL    DISEASES. 

tonic  (as  well  as  performing  its  work  as  a  specific)  during  the  whole  period 
of  its  administration. 

The  method  I  propose,  indeed,  has  all  the  advantage  of  the  coup  sur 
coup  method,  but  its  coup  is  mild.  It  hurts  only  the  disease,  never  the 
patient.  The  "  blow  "  falls  only  during  the  period  of  active  outbreak  of 
the  disease,  while  the  general  treatment  has  the  further  advantage  of  acting 
continuously  as  a  specific  in  eliminating  the  poison  of  syphilis,  and  prevent- 
ing it  from  causing  outbreaks  in  the  way  of  serious  symptoms.  This  treat- 
ment constantly  tends  to  keep  the  disease  down,  and  to  keep  the  patient 
up.  It  does  not  cure  the  disease  so  much  as  it  conducts  the  patient  safely 
through  the  periods  of  the  disease.  It  does  not  prevent  relapse  later  in 
life  with  certainty,  for  occasional  cases  of  such  relapse  do  certainly  occur; 
but  it  ensures  one,  I  believe,  more  positively  against  relapse,  than  any 
other  form  of  treatment — at  least,  than  any  other  with  which  I  am  fa- 
miliar. 

Salivation  I  believe  to  be  harmful.  Much  of  the  odium  which  rests 
upon  mercury  is  undoubtedly  due  to  the  harm  it  has  done  to  the  mouths 
and  stomachs  of  patients  in  times  past,  by  salivation.  In  the  days  when 
it  was  considered  that  the  patient  never  had  arrived  at  his  proper  dose  of 
mercury  until  he  was  caused  to  spit  at  least  a  pint  in  twenty-four  hours, 
how  much  damage  must  have  been  done,  and  how  justly  has  mercury  paid 
the  penalty  by  falling  into  popular  disgrace,  and  by  being  distrusted  by  a 
large  number  of  intelligent  gentlemen,  in  the  profession  as  well  as  out  of  it. 

That  salivation  may  occasionally  do  good  in  desperate  conditions  of 
disease  late  in  syphilis,  I  do  not  deny;  but  certainly  it  has  no  value  as  a 
means  of  general  treatment,  and  I  think  it  can  never  happen  to  a  patient 
early  in  the  disease  without  doing  him  positive  harm. 

The  time  at  -which  the  general  treatment  of  syphilis  shall  be 
commenced  is  a  question  of  great  importance.  Unquestionably  it  should 
be  commenced  as  soon  as  the  disease  is  diagnosticated;  but  the  difficulty 
is  that  diagnosis,  before  the  eruptive  stage — positively  absolute  diagnosis 
— is  rarely  possible  without  confrontation,  and  even  then  there  is  a  chance 
for  error  found  in  the  possibility  of  infection  through  another  source,  or 
in  mediate  contagion. 

Practically,  therefore,  the  treatment  should  not  be  commenced  until 
the  first  general  symptoms  of  syphilis  appear;  the  chancre  with  the  accom- 
panying glandular  engorgement  is  not  enough  to  go  by.  If  treatment  is 
commenced  while  any  doubt  exists,  that  doubt  remains,  and  the  patient 
may  continue  in  doubt  for  the  rest  of  his  life,  to  his  great  discomfort; 
therefore,  although  he  may  demand  treatment,  and  beg  for  it  when  he  has 
a  chancre,  the  surgeon  will  do  him  a  kindness  by  refusing  internal  specific 
measures  until  the  first  general  symptoms  begin  to  appear. 

In  the  rare  cases  in  which  diagnosis  can  be  positively  made,  with- 
out the  chance  for  the  least  possible  doubt — as,  for  instance,  when  a  hus- 
band poisons  his  wife  or  his  child — treatment  may  and  should  be  com- 
menced at  once,  without  waiting  for  general  symptoms;  otherwise  it  is 
safer  for  all  parties  to  wait.  The  patient's  mind  may  be  satisfied,  mean- 
time, by  cutting  out  his  chancre,  and  he  may  be  medicated,  to  his  advan- 
tage doubtless,  with  tonics  of  all  kinds;  but  mercury  should  be  denied 
him. 

I  have  in  the  past  often  deviated  from  this  rule,  and  probably  with 
advantage  to  the  patient  in  most  instances;  but  occasionally  I  have  en- 
countered a  case  which  has  afterward  given  me  much  anxiety,  and  made 
me  dcrabt  ray  diagnosis  greatly.  Such  cases  always  make  one  feel  the  ad- 


SYPHILIS.  117 

vantage  of  a  rule  which  forbids  any  specific  treatment  until  general  symp- 
toms have  declared  themselves.  In  one  case  which  I  remember  well,  there 
was  no  possible  room  for  doubt  about  the  patient's  syphilis.  Every  phys- 
ical feature  of  the  sore  was  perfect,  the  incubation  accurate,  the  ingui- 
nal pleiad  typical;  and,  at  the  patient's  urgent  request,  I  commenced 
treatment.  All  went  well  for  a  year,  but  not  a  solitary  symptom  of  syphi- 
lis appeared.  During  the  second  year,  treatment  having  been  kept  up 
continuously,  and  the  patient  being  in  perfect  health,  my  faith  began  to 
waver,  and  for  several  months  I  thought  it  possible  that  1  had  made  a 
mistake,  and  that  my  patient  had  no  syphilis  at  all.  I  finally  appointed  a 
night,  and  told  him  that,  if  no  symptoms  of  syphilis  had  appeared  before 
that  date,  I  should  stop  all  treatment.  Fortunately  for  the  patient  and 
for  my  diagnosis,  at  his  next  visit  he  showed  me  a  most  characteristic 
mucous  patch  upon  his  throat,  and  the  treatment  was  continued.  Much 
anxiety  in  this  case,  both  on  the  part  of  the  patient  and  of  myself,  might 
have  been  avoided  by  waiting  six  weeks  or  two  months  after  the  chancre, 
before  commencing  treatment. 

X 

DETAIL   OF   THE   TONIC   TREATMENT    OF   SYPHILIS    BY    MERCURY. 

I  have  called  the  method  about  to  be  described  the  tonic  treatment  of 
syphilis,  to  distinguish  it  from  other  methods.  It  is  tonic,  and  therefore 
the  term  is  correct;  but  it  does  not  cure  syphilis  because  it  is  tonic.  It 
cures  the  symptoms  because  it  is  a  specific,  and  the  tonic  action  is  only 
an  accidental  one  found  to  attach  to  the  method.  Even  if  it  were  not 
tonic,  it  would  be  proper  to  use  mercury  in  the  treatment  of  syphilis;  and 
indeed,  mercury  often  is  given,  and  properly  given,  in  such  a  way  as  to  be 
a  specific  devoid  of  tonic  properties,  in  that  it  is  used  in  large  doses — doses 
which  I  have  shown  by  blood  counting  to  be  anything  but  tonic.  When, 
however,  the  specific  medicine  can  be  used  so  as  to  be  at  the  same  time 
a  tonic,  I  think  that  a  step  in  advance  over  the  older  methods  has  been 
made,  and  that  is  the  reason  why  I  have  called  this  method  the  "  tonic 
treatment  of  syphilis." 

The  idea  of  this  treatment  is  best  carried  out  by  using  the  same  drug 
continuously  in  varying  doses.  If  the  preparation  has  to  be  changed  and 
great  accuracy  is  aimed  at,  it  is  necessary  to  make  a  new  set  of  tests  in 
order  to  find  the  tonic  dose.  The  preparation  which  I  have  used  the  most, 
and  with  which  I  am  entirely  satisfied,  is  the  proto-iodide  of  mercury  put 
up  in  France  by  Gamier  and  Lamoureux,  in  the  form  of  sugar-coated 
granules,  containing  exactly  one  centigramme  each  (fa  of  a  grain).  The 
advantages  of  this  preparation  are  that  it  does  not  change  by  climate ;  the 
proto-iodide  remains  fresh  inside  the  sugar  coating,  and  the  latter,  being 
thin  over  the  small  granules,  always  dissolves  in  the  stomach  readily;  the 
preparation  is  a  solid  one,  and  easy  to  carry  around,  and  to  take  without 
causing  comment;  a  liquid  might  be  used,  but  it  would  be  harder  to  man- 
age; the  quantity  of  the  drug  in  the  pills  (one  centigramme)  seems  to  be 
reliable,  and  to  be  accurately  graded  in  the  different  pills;  the  preparation 
is  clean  and  dry,  and  many  doses  may  be  carried  in  a  little  box  or  bottle 
in  the  pocket,  without  taking  up  much  room;  finally,  this  preparation  has 
very  little  of  the  griping  quality  possessed  by  many  specimens  of  the 
proto-iodide  found  in  the  shops.  The  French  granules  are  quite  cheap. 

Many  preparations  doubtless  possess  all  the  good  qualities  I  have  as- 
cribed to  Garnier's  granules;  but,  having  been  well  served  by  these,  I 
have  not  thought  it  well  to  change.  A  number  of  American  manufac- 


118  THE    VENEREAL    DISEASES. 

turers  now  make  gelatin-coated  granules  of  proto-iodide  of  mercury  in 
doses  of  gr.  £,  -£,  \,  and  many  of  them  are  good  preparations.  They  may 
be  obtained  anywhere  in  the  country. 

In  some  cases  the  proto-iodide  produces  griping  pain  in  the  intestine, 
even  when  it  is  given  in  very  small  doses;  but  these  cases  I  find  are  quite 
rare  when  the  French  granules  are  employed. 

Other  preparations  of  mercury,  however,  must  be  at  hand  to  be  em- 
ployed when  the  proto-iodide  does  not  agree.  Perhaps  the  drug  most 
bland  and  most  certain  to  be  found  everywhere  is  blue  pill.  The  size  of 
pill  most  convenient  for  use  I  find  to  be  one-half  a  grain,  and  these  may 
be  made  up  alone,  or  combined  with  a  fifth,  a  quarter,  or  a  half-grain  of  the 
dried  sulphate  of  iron,  according  to  the  formula  so  long  successfully  in 
use  by  the  profession. 

If  pills  are  objected  to  by  the  patient,  he  may  take  gray  powder,  the 
standard  powder  to  use  in  finding  the  dose  being  one-third  or  one-half  a 
grain;  or,  if  liquids  must  be  taken,  owing  to  the  patient's  caprice,  I  know 
of  no  improvement  upon  the  old-fashioned  combinations  of  corrosive 
chloride  with  compound  tincture  of  cinchona,  or,  if  iron  be  needed  with 
the  tincture  of  the  sesquichloride  of  iron,  the  dose  being  so  regulated  that 
one-fiftieth,  or,  perhaps  better,  one-hundreth  part  of  a  grain  of  the  bichlo- 
ride shall  be  the  standard  dose  until  the  tonic  dose  has  been  found  out. 

In  short,  any  preparation  or  combination  of  mercury  may  be  used, 
provided  it  does  not  contain  opium,  the  addition  of  which  would  make  it 
impossible  to  decide  accurately  what  the  tonic  dose  is.  The  standard 
dose  must  be  a  minute  one. 

To  bring  a  patient  under  the  tonic  treatment,  if  there  be  time,  the  fol- 
lowing is  the  best  course:  Let  him  take  one  standard  dose  of  mercurial 
(one  granule  of  the  proto-iodide,  for  example)  after  each  meal  for  two 
or  three  days.  On  the  fourth  day  one  extra  standard  dose  is  added  at 
the  mid-day  meal;  now  four  standard  doses  (granules)  are  taken  daily, 
and  this  is  to  be  continued  for  three  days. 

On  the  succeeding  fourth  day  another  standard  dose  is  added,  the  five 
daily  standard  doses  being  taken  two  in  the  morning,  one  at  noon,  and  two 
at  night.  On  the  next  following  fourth  day,  always  counting  from  the  last 
fourth  day,  another  dose  is  added,  two  standard  doses  being  now  taken 
after  each  meal — six  (granules)  a  day. 

In  this  way  the  amount  of  mercurial  given  is  gradually  increased, 
while  the  patient  uses  bland  food  in  moderate  quantity  and  regulates  his 
habits  as  far  as  may  be,  and  the  dose  is  slowly  increased  every  third  or 
fourth  day,  or  even  every  second  day,  if  the  patient  is  pushed  for  time 
and  the  presence  of  an  eruption  makes  haste  an  object,  until  the  irrita- 
ting or  the  poisonous  action  of  the  drug  begins  to  manifest  itself. 

If  in  any  given  case  the  symptoms  are  so  pressing  that  there  is  not 
time  to  get  the  patient  quietly  under  this  treatment,  there  is  no  objection 
to  treating  him  by  any  of  the  older  methods  until  his  symptoms  abate. 
He  may  be  rapidly  brought  under  the  mild  influence  of  mercury  until  the 
drug  shows  faintly  along  the  edge  of  the  gums,  either  by  inunction,  by 
daily  fumigations,  or  by  gr.  -fa  doses  of  corrosive  chloride  in  tincture  of 
bark,  taken  diluted,  after  meals;  and  when  finally  the  urgent  symptom 
has  fairly  declined,  all  medication  may  be  suspended  for  a  week  or  more, 
ami  then  under  less  pressure  the  mercurial  course  may  be  instituted  as 
directed  above. 

f  )ne  advantage  of  the  French  proto-iodide  granules,  which  was  not 
alluded  to  above  in  the  list  of  its  virtues,  is  that,  although  it  does  not 


SYPHILIS.  119 

gripe  when  given  in  small  quantities,  yet  it  does  show  its  irritating  ef- 
fects, usually,  upon  the  intestine,  before  it  produces  any  trouble  in  the 
mouth.  This  is  not  always  the  case,  but  it  is  the  rule;  consequently, 
during  this  course  of  granules,  diarrhosa  and  griping  pain  are  to  be 
watched  for.  A  slight  looseness  of  the  bowels  is  unimportant.  Such  a 
looseness  often  comes  on  during  the  early  days  of  the  course;  but,  by 
holding  the  drug  at  the  same  dose,  it  subsides,  and  then  the  doses  may 
be  increased  as  before. 

When  a  dose  of  six  to  nine,  or  even  twelve  granules  a  day  in  some 
cases,  has  been  reached,  it  will  produce  a  very  positive  attack  of  diar- 
rhoea, with  pain  in  the  intestines;  and  occasionally  at  the  same  time  the 
breath  will  begin  to  have  the  mercurial  fetor,  and  the  livid  line  will  begin 
to  show  faintly  along  the  edge  of  the  gums  at  the  necks  of  the  teeth, 
while  the  teeth  themselves  become  a  little  sensitive  on  being  snapped 
sharply  together,  and  the  saliva  flows  more  freely.  These  latter  symp- 
toms are  generally  not  much  marked  with  the  proto-iodide,  and  they  may 
be  absent  entirely  while  the  griping  and  diarrhosa  are  quite  positive,  and 
this  feature  I  consider  an  advantage  in  favor  of  the  proto-iodide. 

When  either  of  these  sets  of  symptoms  occur,  the  patient  has  reached 
his  limit.  He  is  taking  what  I  have  called  his  "  full  dose " — a  dose 
which  he  may  continue  to  take  with  the  aid  of  selected  food  and  a  little 
opium,  and  may,  indeed,  in  most  cases,  continue  to  take  without  becom- 
ing salivated.  This  dose  is  anything  but  tonic.  If  it  be  continued,  the 
patient  surely  suffers  in  time,  both  in  the  stomach  and  in  the  quality  of 
his  blood,  while  his  strength  and  physical  powers  are  diminished  by  it. 
This  "  full  dose,"  therefore,  is  only  to  be  used  in  case  of  necessity.  It  is 
specific,  and  possesses  fully  the  antagonistic  influence  to  syphilis  which 
the  mercurials  enjoy;  and  the  patient  may  take  this  dose  for  a  consider- 
able period  without  injury,  if  his  symptoms  require  it,  with  the  aid  of  a 
little  opium  to  give  him  comfort,  or,  I  think,  preferably  without  opium, 
by  changing  his  food,  drinking  boiled  milk,  and  eating  rice. 

This  "  full  dose,"  the  size  of  which  varies  greatly  in  different  individ- 
uals, may  be  maintained  until  the  activity  of  any  existing  symptoms  de- 
clines, and  then  it  should  be  dropped,  and  the  "  tonic  dose  "  of  mercury 
substituted. 

One-half  of  the  "full  dose"  is  a  "tonic  dose,"  and  may  be  continued 
steadily  during  several  years  without  injury  to  the  patient;  if  anything, 
apparently  rather  to  his  advantage,  for  he  feels  well  under  it  in  most 
cases,  he  eats  well,  his  functions  go  on  perfectly,  and  his  blood  is  richer 
in  red  corpuscles  than  it  was  before.  The  condition  is  an  unnatural  one, 
however.  Nature  is  being  outraged  by  the  constant  use  of  a  foreign 
substance,  the  use  of  which  is  only  allowable  in  order  that  it  may  coun- 
teract another  foreign  substance — the  poison  of  syphilis — and  the  less  of 
the  drug  that  can  be  used  with  safety  to  the  patient,  the  better.  There- 
fore, of  late  years,  I  have  been  in  the  habit  of  using,  as  a  continuous 
dose,  a  quantity  somewhat  smaller  than  the  regular  tonic  dose — a  quan- 
tity, for  instance,  equal  to  one-third  instead  of  one-half  of  the  "  full 
dose."  This  dose  is  also  tonic,  and  with  it  I  endeavor  to  persist  without 
interruption,  for  a  long  period  of  time,  in  the  endeavor  to  eliminate  the 
syphilitic  poison  gently,  and  to  keep  its  explosive  outbreaks  within  rea- 
sonable limits.  The  idea  of  the  tonic  dose  is  that  it  shall  be  continued 
daily,  year  in  and  year  out,  for,  in  round  numbers,  about  three  years,  or 
longer — alterations,  of  course,  being  occasionally  made  meantime,  accord- 
ing to  the  varied  necessity  of  the  different  cases. 


120  THE    VENEREAL   DISEASES. 

During  the  existence  of  all  ordinary  moderate  symptoms,  isolated 
patches  of  eruption,  disappearing  general  eruptions,  mucous  patches,  etc., 
the  tonic  dose  may  be  maintained  unvaried,  or  slightly  increased,  accord- 
ing to  the  surgeon's  judgment,  while  local  measures  are  brought  to  bear 
upon  the  local  lesions.  If  more  severe  symptoms  come  on  at  any  time, 
the  tonic  dose  may  be  immediately  increased  to  the  full  dose,  already 
ascertained;  and  after  the  full  dose  has  done  its  work,  it  in  turn  may  be 
again  dropped  to  be  replaced  by  the  tonic  dose.  In  these  emergencies, 
instead  of  increasing  up  to  the  full  dose,  the  tonic  dose  may  be  maintained, 
and  inunction  or  fumigation  resorted  to  until  the  emergency  has  passed. 

These  simple  directions  meet  the  wants  of  most  cases,  until  some  ter- 
tiary symptom  arrives — if,  indeed,  any  tertiary  symptoms  at  all  come  on, 
for  they  may  be  escaped  entirely.  Tertiary  symptoms  call  for  a  variation 
in  the  general  treatment.  The  mercury  may  be  dropped  entirely,  one  of 
the  iodides  being  substituted  if  the  lesion  be  purely  gummatous;  or  the 
mixed  treatment  may  be  called  for,  according  to  the  symptom.  Under 
the  heads  of  the  various  symptoms,  it  will  be  indicated  which  of  the 
special  forms  of  treatment  is  required.  When  the  mixed  treatment  is 
indicated,  one  of  the  best  combinations  is  a  solution  of  the  biniodide  of 
mercury  in  a  solution  of  the  iodide  of  potassium.  This  is  a  reasonable 
chemical  combination.  The  granules  of  the  proto-iodide  may  be  con- 
tinued, if  thought  best,  while  the  iodides  are  given  separately;  but  this 
treatment  may  result  in  the  formation  of  a  certain  amount  of  the  binio- 
dide of  mercury  (a  very  active  preparation)  in  the  stomach,  and  the  other 
course  is  therefore  preferable. 

After  the  mixed  treatment  or  the  iodides  alone  have  accomplished 
•what  was  expected  of  them,  it  is  well  that  the  patient  should  return  again 
to  his  tonic  dose  of  the  granules,  and  continue  them  until  it  is  thought 
best  to  stop  all  treatment. 

In  case  of  any  intercurrent  malady  not  syphilitic  in  nature,  coming  on 
during  a  long  mercurial  course,  the  latter  may  be  stopped  at  once  and 
resumed  when  the  intercurrent  malady  has  passed  away.  The  mercury 
should  be  stopped  also  during  any  attacks  of  acute  indigestion,  diarrhoea, 
and  the  like. 

The  time  at  -which  a  tonic  course  of  the  mercurial  specific 
may  be  stopped. — This,  like  all  other  points  in  connection  with  syphilis, 
is  subject  to  variation.  About  three  years  is  a  full  course  for  most  peo- 
ple, while  two  years  and  a  half,  or  even  two  years,  answers  well  enough 
in  some  cases.  Six  months  of  entire  immunity  from  symptoms,  at  the 
very  least,  or,  better  still,  a  year's  freedom  from  evidences  of  the  disease, 
is  desirable  before  the  tonic  treatment  is  stopped.  In  some  cases  where 
smoking  is  persisted  in,  an  occasional  scaly  patch  on  the  side  or  tip  of 
the  tongue,  or  inside  the  lips  or  cheeks,  need  not  be  regarded  as  a  symp- 
tom serious  enough  to  make  the  six  months  test  invalid.  It  is  better 
that  no  symptom  whatsoever  suggesting  syphilis  should  have  occurred; 
but  it  becomes  a  matter  of  special  judgment  in  some  cases  whether  the 
persistence  of  these  mild  mouth  lesions,  for  cause  (smoking),  may  not  be 
disregarded,  provided  there  is  and  has  been  nothing  else  about  the  pa- 
tient for  a  long  time  to  suggest  the  persistence  of  the  existence  of  syph- 
ilis. Occasionally,  non-syphilitic  patients  are  found  in  whom  smoking 
will  produce  erosions  and  scaly  patches  within  the  mouth  absolutely  iden- 
tical with  the  lesions  found  in  syphilis.  Should  such  a  patient  get  the 
disease,  it  is  not  fair  to  let  his  constitutional  peculiarities  be  ascribed  to  a 
syphilitic  cause. 


SYPHILIS.  121 

If  relapses  occur  after  the  cessation  of  treatment,  they  must  be  man- 
aged according  to  their  necessities,  generally  best  by  the  mixed  treat- 
ment; and  then,  finally,  a  tonic  mercurial  course  may  be  instituted  for  a 
few  months,  more  or  less,  according  to  the  judgment  of  the  surgeon,  and 
proportionate  to  the  intensity  of  the  relapse  and  its  obstinacy. 

Many  patients  will  not  follow  continuously  the  strict  course  which  has 
been  detailed;  but  many  others  do  follow  it  conscientiously,  the  more 
readily  as  they  are  intelligent  and  have  the  nature  of  the  disease  ex- 
plained to  them,  together  with  the  theory  of  the  treatment. 


CHAPTER  VII. 

THE   GENERAL  TREATMENT   OF   SYPHILIS — CONTINUED. 

Mercurial  Fumigation. — Simple  Method  of  taking  a  Bath  at  Home. — The  Inunction 
of  Mercury. — Other  Methods  of  giving  Mercury. — The  Treatment  of  Salivation. 
— The  Local  Treatment  of  Syphilitic  Lesions  of  the  Integument ;  of  Mucous  Mem- 
branes.— The  Iodides  and  the  Preparations  of  Iodine. — The  Evil  Effects  of  the 
Iodides. — The  Dose  of  the  Iodides. — The  Mixed  Treatment. — When  to  cease  giv- 
ing the  Iodides. — Zittman's  Decoction. 

Mercurial  fumigation. — Before  making  use  of  the  standard  dose, 
in  order  to  find  the  full  dose,  and  the  tonic  dose,  in  a  particular  case;  or, 
after  the  tonic  dose  has  been  ascertained  and  where  it  is  desirable  to  sud- 
denly increase  the  mercurial  influence  in  order  to  counteract  sone  ten- 
dency to  activity  on  the  part  of  the  syphilitic  symptoms — instead  of  put- 
ting the  patient  upon  his  full  dose  of  mercury,  he  may  be  retained  at  the 
tonic  dose,  and  the  mild  but  certain  influence  of  mercurial  fumigation 
brought  to  bear  upon  him. 

Mercury  in  vapor  acts  very  promptly  and  very  kindly.  The  obstacles 
to  its  extended  use  are  the  difficulty  of  its  application,  the  time  required 
to  give  a  bath,  the  impossibility  of  using  it  secretly  at  home  (for  syphi- 
litic patients  are  always  shy  of  being  discovered  while  taking  medicine), 
and  the  expense  if  the  baths  are  taken  in  an  outside  establishment. 

The  value  of  the  vapor,  however,  is  so  considerable,  in  many  cases,  that 
its  use  for  emergencies  should  be  placed  within  the  reach  of  all.  In  many 
ulcerated  and  pustular  lesions,  and  in  cases  where  persistent  and  chronic 
relapse  occurs  in  a  patient  with  irritable  stomach  and  general  debility, 
the  vapor-bath  renders  invaluable  service.  When  pushed  too  far,  mer- 
curial vapor  may  cause  salivation  or  diarrhcea,  but  it  rarely  does  so  when 
watched;  a  sense  of  weakness,  with  general  depression,  attended  by  more 
or  less  trembling  (perhaps  positive  mercurial  tremor),  is  one  of  the  more 
common  indications  that  the  baths  are  being  pushed  too  rapidly. 

In  a  regular  mercurial  bathing  establishment,  the  patient  sits  naked 
in  a  box,  sometimes  with  the  head  in  (if  the  fumes  are  not  disagreeable 
and  do  not  induce  coughing),  sometimes  with  the  head  out.  A  little  steam 
is  let  into  the  chamber,  the  temperature  is  raised  to  90°  F.  or  thereabouts, 
and  when  the  body  is  damp  and  warm,  the  mercurial  to  be  used  is  vola- 
tilized, and,  permeating  the  chamber,  settles  upon  the  moist  skin,  where  it 
becomes  precipitated — changed  probably  into  the  bichloride  by  contact 
with  the  perspiration,  and  as  such  absorbed.  If  the  head  is  in  the  fumiga- 
ting chamber,  a  certain  amount  of  the  vapor  is  directly  absorbed  by  the 
lungs. 

Fifteen  to  twenty  minutes  is  ample  time  for  such  a  bath,  which  should 
be  terminated  sooner  if  the  patient  grows  faint.  The  best  form  of  mer- 
curial for  the  bath  I  believe  to  be  the  black  oxide,  in  a  dose  for  volatili- 


SYPHILIS. 


123 


zation,  at  first,  of  one  drachm,  afterward  of  two  drachms.  Calomel  is 
often  used,  and  the  sulphuret  of  mercury,  in  doses  of  3  i-  5  but  both  of  these 
substances  irritate  the  lungs  of  some  patients,  and  may  induce  violent 
coughing.  When  they  are  used,  therefore,  the  head  should  be  kept  out- 
side the  fumigating  chamber. 

Twice  a  week  is  generally  often  enough  to  repeat  the  bath.  In  some 
eases,  where  they  are  well  borne,  I  have  repeated  them  daily,  for  a  time, 
watching  the  patient  carefully  for  the  effect  of  mercury. 

After  the  bath  the  patient  should  wrap  himself  up  in  a  warm  blanket, 
and  rest  quietly  for  an  hour  or  more,  until  he  has  become  thoroughly  dry 
without  the  use  of  a  towel. 

The  form  of  bath  above  described  is  a  good  one,  but  it  is  an  expen- 
sive luxury,  and  not  to  be  obtained  at  all  by  patients  in  the  country. 
Under  circumstances  calling  for  a  bath,  where  the  bathing  establishment 
may  not  be  suitable,  an  excellent  substitute,  answering  all  purposes,  may 
be  taken  by  the  patient  in  his  own  house,  at  a  merely  nominal  cost.  The 
appropriate  essentials  for  such  a  bath  are:  an  alcohol-lamp  with  one  or 
two  good  burners,  and  a  piece  of  tin  bent  into  the  form  of  a  table  (Fig. 
1),  of  such  height  that  the  flame  will  spread  itself  evenly  upon  the  under 
surface  of  the  tin.  The  figure  represents  the  flames  of  the  lamp  as  being 
by  far  too  small.  I  have 
found  upon  such  a  table, 
that  one  good  flame  of 
a  spirit-lamp  will  vola- 
tilize half  a  drachm  of 
calomel  in  four  and  one- 
half  minutes,  and  the 
same  amount  of  cinnabar 
in  six  minutes.  One  flame 
is  therefore  ample,  and  it 
need  not  be  a  very  large 
flame  if  the  sheet  of  tin 
be  reasonably  thin. 

Both  calomel  and  cinnabar  volatilize  quite  easily  by  this  method;  the 
oxides  require  more  heat  and  more  time.  I  have  sometimes  used  gray  pow- 
der, which  does  very  well.  Both  calomel  and  cinnabar  (and  especially  the 
latter)  may  cause  coughing,  but  generally  the  bath  can  be  so  managed 
that  the  patient  is  not  materially  discomforted  by  it.  If  cinnabar  be  used, 
the  patient  may  keep  his  head  out,  and  retire  into  another  room  immedi- 
ately after  the  bath.  On  the  whole,  my  experience  leads  me  to  prefer 
calomel  in  this  form  of  bath,  commencing  by  volatilizing  a  powder  of  twenty 
grains,  and  working  up  to  a  drachm. 

Domestic  vapor-bath. — The  simple  method  of  taking  the  bath  is  as 
follows:  the  patient  sits  naked  on  a  cane-bottomed  chair,  holding  close 
around  his  neck,  under  his  chin,  a  couple  of  blankets,  which  may  be 
pinned  in  place  so  as  to  envelop  the  patient  and  the  whole  chair  down 
to  the  floor.  Under  the  blanket  is  placed  the  little  tin  table  beneath  the 
chair,  with  its  spirit-lamp  unlighted,  the  dose  of  calomel  lying  on  top  of 
the  tin  table.  Under  the  chair,  also,  is  placed  a  pan  of  hot  water. 

The  patient  sits  quietly  over  the  hot  water  until  his  skin  has  become 
warmed  up  and  slightly  moist,  then  he  stoops  down,  lights  a  match,  lifts 
the  edge  of  the  blanket,  and  lights  the  spirit-lamp.  He  may  leave  this 
light  burning  until  the  bath  is  finished,  if  he  desires,  or  he  may  extinguish 
it  in  five  or  ten  minutes,  according  to  the  amount  of  calomel  to  be  voiatil- 


Fio.  1. 


124  THE    VENEREAL    DISEASES. 

ized  and  the  degree  of  heat  he  experiences.  He  then  sits  quietly  for  per- 
haps ten  minutes  longer  in  the  fumes,  occasionally  opening  the  front  of 
the  blankets  to  breathe  a  whiff,  if  the  vapor  does  not  irritate  the  air-pas- 
sages, and  his  bath  is  over.  He  now  wraps  himself  up  in  the  inside  blan- 
ket in  which  he  has  taken  his  bath,  and  remains  so  wrapped,  lying  down 
until  he  has  cooled  off,  after  which,  without  using  a  towel,  he  goes  to  bed. 
In  the  morning  he  may  take  a  soap  and  warm  water  bath  if  he  desires  it. 

The  effects  of  mercurial  vapor  by  inhalation  may  be  obtained  when  a 
patient  is  unable  to  leave  his  bed,  by  volatilizing  calomel  or  cinnabar  near 
his  nose  upon  a  sheet  of  tin,  or  even  upon  a  hot  brick.  Inhalations  of 
this  sort  are  of  incalculable  value  in  some  cases  of  mouth  and  throat 
lesions,  when  the  patient  can  make  the  inhalations  without  coughing, 
which  he  generally  can  do  if  they  are  commenced  mildly  and  often  re- 
peated, minute  quantities  of  mercury  being  volatilized  at  a  time. 

These  simple  means  place  the  mercurial  vapor  within  the  reach  of  all; 
and  I  think  the  more  the  vapor  is  used  in  emergencies,  the  more  highy 
will  it  be  esteemed. 

MERCUBY   BY   INUNCTION. 

Inunction  is  the  best  method  of  introducing  mercury  into  the  bodies 
of  infants,  and  many  believe  that  it  is  the  best  method'  in  the  adult.  The 
main  objections  to  it  are  that  it  is  dirty,  and  so  irritates  the  integument 
in  some  cases  that  it  cannot  be  used  for  any  great  length  of  time. 
Where  it  agrees  it  is  an  excellent  method,  especially  to  use  in  conjunction 
with  the  tonic  internal  treatment,  to  meet  such  emergencies  as  call  for 
an  increase  in  the  amount  of  the  mercurial  employed.  It  is  as  good  a 
method  as  that  by  fumigation,  for  sparing  the  stomach,  and  is  very  useful 
in  those  cases  in  which  that  organ  must  be  restricted  to  its  natural  func- 
tion, the  digestion  of  food.  It  has  the  advantage  over  fumigation  that  it 
may  be  carried  out  in  the  utmost  secrecy. 

There  are  many  methods  by  which  mercury  may  be  introduced  through 
the  skin  into  the  blood.  Ordinarily,  the  process  is  one  of  friction;  and 
in  this  country  the  patient  generally  does  the  rubbing  for  himself,  with  his 
own  bare  hand.  In  some  parts  of  the  world  inunction  is  practised  by 
professional  rubbers,  who  often  wear  gloves. 

The  amount  of  absorption  which  takes  place  by  the  skin  is  very  vari- 
able in  different  individuals.  A  prompt  effect  is  produced  in  some  patients, 
a  very  slow  effect  in  others;  consequently,  where  the  course  must  be  long 
or  the  dose  at  all  accurate,  this  method  is  obviously  inappropriate.  More- 
over, skins  differ  materially  in  their  irritability  upon  the  contact  of  mer- 
curial preparations.  Some  patients  will  wear  a  patch  of  mercurial  oint- 
ment bound  upon  the  skin  for  weeks  without  showing  any  local  redness 
of  the  skin,  while  in  others  each  inunction  is  followed  by  local  redness  and 
itching,  and  a  persistence  of  the  application  by  an  outcrop  of  the  so-called 
mercurial  eczema  which  distresses  the  patient  considerably  by  its  itching, 
and  is,  relatively,  quite  chronic  in  character  and  slow  to  disappear. 

In  the  friction  method  of  inunction  three  preparations  are  in  common 
use  :  mercurial  ointment,  the  different  oleates,  solutions  of  corrosive  sub- 
limate. Of  these  three  the  mercurial  ointment  is  cheap,  most  easily  pro- 
cured, and  generally  preferred.  Corrosive  sublimate  is  cheap  also  and 
clean,  but  the  element  of  danger  which  its  use  involves  is  a  bar  to  its  gen- 
eral employment.  The  oleates  are  nicer  preparations,  but  are  more  ex- 
pensive. 


SYPHILIS.  125 

When  mercurial  ointment  is  to  be  rubbed  in,  from  half  a  drachm  to  a 
drachm  is  a  dose,  to  be  used  once  daily,  preferably  at  night.  The  skin  to 
be  anointed  should  be  thin,  for  the  absorption  of  mercurial  ointment  is 
not  active  ;  therefore,  the  flexures  of  the  various  joints  are  usually  chosen, 
although  any  part  of  the  integument  will  answer.  Thus,  Sturgis,  of  New 
York,  prefers  the  soles  of  the  feet,  and  the  patient  does  his  own  friction 
•while  walking  about. 

The  portion  chosen  for  inunction  is  to  be  slowly  and  firmly  rubbed 
with  the  ointment  by  means  of  the  bare  fingers  or  the  whole  hand,  for 
something  like  twenty  minutes  or  half  an  hour,  preferably  at  night.  The 
task  is  laborious  if  properly  done.  After  rubbing  the  ointment  in  as 
thoroughly  as  possible,  the  part  may  be  bound  up  in  dry  flannel  and  left 
for  twenty-four  hours,  when  it  should  be  carefully  washed  with  soap  and 
warm  water,  and  another  friction  performed  upon  another  portion  of  the 
integument.  By  the  time  all  the  flexures  of  the  joints  have  been  gone 
over,  the  spot  first  used  will  be  ready  for  service  again,  and  so  on  until 
the  occasion  for  inunction  ceases. 

When  the  oleates  of  mercury  are  used,  the  five,  ten,  or  twenty  per 
centum  preparations  may  be  employed,  according  to  the  irritability  of  the 
skin  and  the  effect  it  is  desired  to  produce. 

The  twenty  per  cent,  preparation  is  most  commonly  employed.  It  is 
absorbed  more  easily  than  mercurial  ointment,  and,  therefore,  has  more 
effect;  but  it  is  equally  irritating  to  most  skins.  It  may  be  rubbed  in 
anywhere  upon  the  surface,  commencing  with  a  half-drachm  dose  and  in- 
creasing to  a  drachm,  and  treating  the  surface  in  all  respects  as  has  been 
suggested  above  for  mercurial  ointment.  If  mercurial 'eczema  occurs,  it 
may  be  treated  with  any  bland  ointment — oxide  of  zinc,  for  example. 
The  five  per  centum  oleate  may  be  rubbed  upon  the  spot  daily,  in  many 
persons,  without  creating  any  marked  disturbance  of  the  skin. 

The  process  of  cutaneous  application  of  the  bichloride  of  mercury  is 
to  simply  wash  the  skin  with  a  watery  solution  of  corrosive  sublimate  and 
allow  it  to  dry  on.  From  one-quarter  to  one-half  a  grain,  or  more,  may 
be  used  at  a  time  in  this  way,  dissolved  in  a  dessert-spoonful  or  a  table- 
spoonful  of  water.  It  is  dangerous  to  use  an  actively  poisonous  drug  in 
such  quantities  generally,  especially  if  there  be  any  erosions  of  the  skin, 
such  as  might  be  found  in  an  early  general  syphilitic  eruption.  Detmold, 
of  New  York,  praises  this  plan  highly. 

Corrosive  sublimate  is  used  in  a  full  bath  sometimes,  especially  for 
children;  but  it  can  hardly  be  safe  for  general  adoption. 

Teale's  method  of  inunction,  as  it  is  called,  consists  in  binding  upon 
an  arm  or  a  leg  a  piece  of  bandage  (or  flannel  cloth),  upon  which  mercu- 
rial ointment  has  been  thickly  smeared.  The  bandage  is  kept  in  place  at 
discretion,  the  surface  of  the  skin  beneath  it  being  inspected  daily,  and 
the  bandage  removed  and  placed  elsewhere  when  the  skin  begins  to  show 
any  signs  of  redness,  or  the  patient  complains  of  local  itching.  By  this 
means  there  is  a  continuous  action  of  the  mercury  upon  the  skin  day  and 
night,  until  the  ointment  dries  up,  when  it  must  be  freshened  with  oil, 
or  a  new  plaster  applied. 

This  method  is  mild  and  continuous  in  its  action,  and  with  certain 
skins  works  admirably. 

Of  the  other  methods  of  introducing  mercury  into  the  body,  that  by 
rectal  suppository,  which  has  been  abandoned  by  its  originator,  Zeissl,  is 
not  so  good  as  by  the  skin  or  by  fumigation;  and  that  by  subcutaneous 
injection,  even  of  the  albumiuates  of  mercury,  though  undoubtedly  prompt 


126  THE   VEXEREAL   DISEASES. 

and  effective,  is  painful,  and  apt  to  be  followed  by  local  inflammatory  in- 
durations, and  even  abscesses,  which  practically  make  it  unsuitable  for 
general  use,  even  during  emergencies,  since  we  possess  so  many  better 
methods. 

The  direct  local  influence  of  mercury  has  been  proved  by  subcutaneous 
injection  of  the  drug,  since  it  has  been  found  that,  if  a  patch  of  eruption 
be  injected,  it  gets  well,  while  a  similar  patch,  more  or  less  distantly  sit- 
uated, is  not  modified  by  the  general  effect  upon  the  system  of  the  small 
amount  of  mercury  employed. 

Among  the  special  methods  of  giving  mercury,  the  plan  known  as 
Trousseau's  must  not  be  forgotten.  By  this  plan  minute  doses  of  calo- 
mel, anywhere  from  the  sixtieth  to  the  tenth  of  a  grain,  are  given  hourly, 
or  at  short  intervals,  with  great  effect  in  some  cases  in  overcoming  the  in- 
tense headache  of  early  syphilis,  and  for  the  purpose  of  rapidly  bringing  a 
patient  under  the  full  influence  of  mercury.  One-tenth  of  a  grain,  hourly, 
will  show  in  the  mouth,  in  the  case  of  some  patients,  within  twenty-tour 
hours. 

THE   TREATMENT    OP   SALIVATION. 

In  a  properly  regulated  treatment  salivation  should  never  occur.  In 
ascertaining  what  the  "full  dose  "of  mercury  is  in  a  given  case,  the  gums 
may  be  touched,  as  the  expression  is;  but  this  condition  cannot  fairly  be 
called  salivation,  although  it  is  the  first  stage  of  it.  In  maintaining  the 
full  dose,  the  mouth  is  kept  constantly  in  a  condition  of  mild  irritation, 
and  necessarily  so,  in  some  instances,  when  the  symptoms  are  severe. 
Under  these  circumstances,  especially  if  it  seems  probable  that  the  full 
dose  will  have  to  be  maintained  for  a  considerable  period,  certain  precau- 
tions should  be  taken  with  the  mouth  in  order  to  allow  the  mercury  full 
chance  without  in  any  way  encouraging  its  disagreeable  effect  upon  the 
mouth. 

The  teeth,  it  is  presumed,  have  been  properly  attended  to,  and  the  tar- 
tar removed  by  a  dentist.  All  the  precautions  detailed  in  speaking  of 
the  hygiene  of  the  mouth  (p.  112)  should  also  be  put  in  force.  Besides 
these  precautions,  only  three  others  need  to  be  insisted  upon  ;  they  are  : 
the  bath,  a  diuretic,  and  the  internal  use  of  the  chlorate  of  potash. 

The  bath  should  be  used  quite  hot  at  night,  and  the  patient  advised 
to  remain  for  a  number  of  minutes  in  the  warm  water.  Then  he  should 
dry  his  skin  under  very  smart  friction  with  a  soft  towel.  In  this  way  the 
circulation  of  the  skin  is  rendered  active,  and  the  dead  epidermis  rolled 
off  in  quantities  by  the  friction.  The  function  of  the  skin  as  an  excretory 
organ  is  intensified,  and  more  mercury  than  usual  escapes  in  this  direction, 
thus  taking  off  some  of  the  work  from  the  mouth. 

A  diuretic  acts  in  the  same  way,  increasing  the  excretory  activity  of 
the  kidney,  and  allowing  more  mercury  to  escape  from  the  body  by  this 
channel. 

^  Finally,  the  well-known  soothing  influence  of  the  chlorate  upon  the 
irritated  mouth  and  fauces  should  be  called  into  play.  About  a  drachm 
of  the  chlorate  of  potash  in  twenty-four  hours  is  generally  enough  to  be 
taken. 

9 .     Potass,  chlorat 3  i. 

Aquae  gaultheriae §  iij, 

M. 

S.     Teaspoonful  hourly  in  a  tablespoonful  of  flaxseed  tea. 


SYPHILIS.  127 

If  double  doses  are  taken  in  the  early  morning  and  during  the  even- 
ing, about  the  proper  amount  in  the  twenty-four  hours  will  be  consumed. 

As  salivation  approaches,  the  signs  noticed,  as  indicating  that  the  gums 
are  touched,  become  intensified.  The  stale  odor  of  the  breath  becomes 
positively  offensive,  quite  peculiar  and  characteristic — the  mercurial  fetor, 
as  it  is  called.  The  tongue  becomes  heavily  coated,  and  the  peculiar,  bit- 
ter, coppery  taste  of  which  the  patient  has  been  complaining,  grows  sensi- 
bly more  intense  and  more  disagreeable,  especially  upon  awakening  in  the 
morning.  The  gums  grow  puffy,  soft,  and  fungating  along  the  line  of  the 
necks  of  the  teeth,  more  livid  in  color,  bleeding  easily  upon  the  lightest 
touch,  as  during  brushing  the  teeth,  even  with  the  softest  tooth-brush. 
Finally,  the  flow  of  saliva  grows  more  and  more  profuse,  partly  watery 
and  partly  tenacious.  It  flows  over  upon  the  patient's  chin,  and  soils  his 
clothes.  At  night  it  runs  out  from  the  angles  of  his  mouth,  and  wets  his 
pillow.  With  these  signs  the  stomach  is  often  badly  upset,  diarrhoea 
comes  on,  the  complexion  becomes  pallid,  livid,  the  appetite  fails,  and 
headache  is  often  present,  with  great  depression  of  spirits. 

At  last  the  tongue  may  swell  so  as  to  be  too  large  for  the  mouth,  and 
with  it  the  lips  and  cheeks  become  tumid.  Ulcers  appear  all  over  the  in- 
side of  the  mouth  and  along  the  gums.  The  purple  gums  bleed  freely,  the 
loosened  teeth  project,  and  drop  from  their  sockets,  while  more  or  less  ex- 
tensive portions  of  bone,  or  of  the  soft  parts,  necrose  and  slough  away. 

Such  an  intense  condition  of  salivation  as  that  last  depicted  is  very 
rarely  encountered  at  the  present  day,  but  it  need  not  be  waited  for;  all 
conditions  of  active  salivation  demand  prompt  measures  for  their  relief. 

All  the  means  of  relief  already  detailed  under  the  head  of  hygiene  of 
the  mouth,  p.  112,  and  directed  for  the  restraint  of  salivation  when  the 
gums  are  mildly  touched,  should  be  kept  in  force,  as  far  as  may  be,  and 
atropine  used  in  solution  under  the  skin.  • 

No  one  remedy  perhaps  acts  as  kindly  as  this.  Of  the  following  solu- 
tion— 

3 .     Atropue  sulph gr.  i. 

Aquse §  i. 

M. 

five  minims  may  be  thrown  under  the  skin,  the  effect  upon  the  pupil 
watched,  and  the  dose  repeated  every  four  to  six  hours,  until  the  pupils 
are  widely  dilated.  The  effect  of  this  remedy  upon  the  salivary  secretion 
is  often  very  prompt,  and  the  general  influence  over  salivation  quite 
marked. 

Chlorate  of  potash  in  solution,  in  cold  tea,  about  one  or  two  drachms 
to  the  pint,  with  a  scruple  of  carbolic  acid,  according  to  the  sensitiveness 
of  the  swollen  mouth,  should  be  constantly  used  as  a  mouth-wash,  and 
gradually,  as  they  can  be  borne,  stronger  and  more  astringent  washes. 
To  all  of  these  a  little  carbolic  acid  should  be  added,  for  the  mouth  and 
its  secretions  are  most  foul  and  need  sweetening  greatly.  A  reasonably 
good  mouth-wash  is  the  following,  diluted  at  first  with  warm  water,  should 
it  prove  too  astringent: 

B.     Acid,  carbolic gr.  x. 

Acid,  tannic 3  i. 

Tr.  my  rrhse 3  i j. 

Potassas  chloratis 3  V). 

Mellis 3  ij. 

Aquae  menth.  pip q.  s.  ad    §  viij. 


128  THE    VENEREAL    DISEASES. 

Labarraque's  solution  diluted,  or  a  mild  solution  of  borax  or  of  perman- 
ganate of  potash,  may  be  used  as  a  substitute  for  the  carbolic  acid  prepa- 
rations should  the  latter  be  offensive,  as  tbey  are  to  some  patients. 

Diarrhoea  in  these  cases  may  be  disregarded,  unless  it  is  exceptionally 
severe.  Nourishment  must  be  maintained  mainly  by  milk,  eggs,  soups, 
and  soft  food. 

THE   LOCAL  TREATMENT   OP   SYPHILITIC   LESIOXS. 

The  local  treatment  of  syphilis,  although  subordinate  to  the  general 
treatment,  is  nevertheless  of  great  importance  in  many  cases.  This  is 
especially  true  in  regard  to  mouth  lesions,  and  those  occurring  about  the 
anus  and  genitals  in  either  sex.  It  is  often  equally  important  in  connec- 
tion with  a  general  syphilitic  eruption,  where  spots  on  the  face  and  on 
the  hands  must  be  removed  with  all  possible  speed,  and  in  some  cases  of 
ulcers  which  require  local  as  well  as  general  treatment  for  their  prompt 
removal. 

In  connection  with  a  description  of  the  varied  local  lesions,  some  of 
the  local  measures  of  treatment  most  appropriate  to  them  will  be  alluded 
to;  but,  for  the  sake  of  avoiding  endless  repetition,  it  is  well  to  group 
under  one  head  all  general  remarks  about  the  local  treatment  of  the 
varied  lesions  of  syphilis,  only  repeating  afterward  where  the  treatment 
is  to  be  emphasized. 

In  general,  then,  it  may  be  said  that  all  the  local  expressions  of  syphilis 
should  be  treated  with  respect,  not  irritated  by  much  handling,  by  dirt, 
by  allowing  the  secretions  to  be  retained  and  to  undergo  decomposition. 
Ulcers  should  be  kept  clean,  discharges  of  all  sorts  should  be  frequently 
washed  away,  tobacco  prohibited  where  mouth  lesions  exist. 


LOCAL  MEASURES  APPLICABLE  TO  LESIONS  ON  THE  SKIN". 

The  local  treatment  of  chancre  is  detailed  along  with  the  description  of 
the  lesion.  The  early  general  eruptions  require  no  local  treatment  other 
than  cleanliness,  unless  it  be  for  such  portions  of  the  eruption  as  appear 
upon  the  face  and  hands.  These  portions,  therefore,  may  be  treated  top- 
ically while  the  rest  of  the  eruption  is  allowed  to  subside  under  general 
medication. 

The  best  topical  applications  for  all  the  forms  of  secondary  and  inter- 
mediary syphilis  appearing  upon  the  skin  are  the  different  preparations 
of  mercury.  Most  of  the  tertiary  lesions  do  well  also  under  a  local  use  of 
the  mercurials;  but  some  ulcerative  forms  seem  to  thrive  better  when 
dressed  with  iodoform  or  choral. 

The  mercurials,  to  be  effective  of  good  by  local  application,  should  be 
graded  in  strength  so  as  to  stimulate  without  irritating  the  surface.  Con- 
sequently there  must  be  a  range  in  the  strength  of  all  applications  em- 
ployed, and  it  is  well  in  a  given  case  to  begin  with  a  mild  ointment,  in- 
creasing its  strength  according  to  its  effect.  Dry  lesions  call  for  more 
strength  in  the  local  application  than  excoriated  surfaces  require. 

The  preparations  from  which  I  have  derived  the  most  service  are  the 
following  : ' 

1  Most  of  these  have  appeared  in  a  monograph  on  the  "  Tonic  Treatment  of  Syphi- 
lis," published  in  1877,  p.  76. 


SYPHILIS.  129 

R.     Hydrarg.  oleat 5  or  10  per  cent. 

Or— 

R.     Hydrarg.  chlorid.  corrosiv gr.  i. — v. 

Glycerinae 3  ss. 

Spts.  rect., 

Aquae  ros aa    §  ss. 

M. 
Or— 

]J .     Hydrarg.  chlorid.  mitis 3  i. — ij. 

Ungt.  aquae  ros. * §  i. 

M. 
Or— 

$ .     Hydrarg.  ammoniat 3  i. — ij. 

Ungt.  aquae  ros §  i. 

M. 
Or— 

]J .     Hydrarg.  oxid.  rub 3  ss. — ij. 

Ungt.  aquae  ros §  i. 

M. 
Or— 

]J.     Ungt.  hydrarg.  nitratis q.  s. 

To  be  used  in  the  beginning  much  diluted. 

Or— 

3 .     Hydrarg.  iodid.  virid gr.  xv. — 1. 

Ungt.  aquae  ros §  i. 

M. 
Or— 

]J .     Hydrarg.  oxid.  flav gr.  xx. —  3  iss. 

Ungt.  aquae  ros |  i. 

M. 

Among  these  preparations,  perhaps  the  best  are  the  lotion  of  the  bi- 
chloride, the  white  precipitate  and  the  citrine  ointments.  One  or  the  other 
of  them  will  be  found  to  serve  a  good  purpose  in  the  case  of  the  different 
cutaneous  lesions,  dry  or  moist.  The  bichloride  solution,  I  think,  acts 
best  for  dry,  scaly  patches  upon  the  palms  or  elsewhere. 

Mucous  patches  about  the  angles  of  the  mouth,  upon  the  lips  and 
face,  generally  do  well  under  the  local  application  of  the  solution  of  the 
bichloride  of  mercury.  If  this  does  not  hurry  them  away,  one  or  two 
light  applications  of  the  acid  nitrate  of  mercury  usually  leaves  nothing 
to  be  desired  in  the  way  of  efficiency. 

When  mucous  patches  occur  about  the  anus,  under  the  foreskin,  on 
the  sides  of  the  scrotum,  or  about  the  vulva,  between  the  toes,  under  the 
breast  in  the  female,  in  any  region  where  overlying  portions  of  the  skin 
keep  the  surfaces  of  the  lesions  sodden,  retain  their  secretion  and  encour- 
age putridity  of  the  moisture  as  it  collects — in  any  of  these  contingencies, 
soap  and  warm  water,  followed  by  a  mild  dilution  of  Labarraque's  solu- 
tion, of  permanganate  of  potash,  or  of  carbolic  acid,  are  great  aids  to 
treatment. 

1  Any  other  bland  excipient  may  be  used.    Vaseline  is  perhaps  the  best  if  the  oint- 
ment is  to  be  teptfor  any  length  of  time,  since  it  does  not  become  rancid.    Ointments 
made  with  vaseline,  however,  are  somewhat  less  active  than  if  another  fat  is  used  aa 
an  excipient. 
9 


130  THE   VENEREAL   DISEASES. 

The  lesions  must  also  be  kept  dry,  if  possible,  either  by  interposing 
layers  of  thin  old  linen,  absorbent  cotton,  or  prepared  lint,  between  the 
surfaces  which  lie  in  contact,  or  by  a  plentiful  use  of  some  absorbent 
powder,  such  as  lycopodium,  starch,  oxide  of  zinc.  A  very  effective  way 
of  treating  these  lesions  is  to  dust  them  plentifully  and  often  with  pure 
calomel,  or  with  calomel  in  varying  proportions  combined  with  one  of  the 
inert  dry  powders  mentioned  above. 

All  that  is  required  besides  this,  even  in  bad  cases,  is  to  touch  the  sep- 
arate moist  lesions  with  solutions  of  nitrate  of  silver  of  varying  strength, 
gr.  x. —  3  j.  to  the  ounce  of  water  ;  or  lightly  with  the  solid  stick  of  lunar 
caustic;  or,  perhaps  better  still,  to  use  the  solution  of  the  bichloride  of 
mercury  already  recommended  for  skin  lesions. 

Ulcerated  lesions  upon  the  integument,  due  to  late  syphilis,  gener- 
ally improve  under  various  local  mercurial  applications.  The  black  and 
yellow  washes  of  the  pharmacopoeia  serve  a  good  purpose,  as  does  also 
a  mild  solution  of  the  bichloride  of  mercury,  or  dusting  the  surface  with 
calomel. 

Gummatous  and  serpiginous  ulcers  sometimes  improve  under  these  ap- 
plications, but  sometimes  they  do  not.  In  such  case  it  is  well  to  try  iodo- 
form  in  fine  powder,  or  rubbed  up  into  a  paste  with  gylcerine,  or  dissolved 
in  chloroform,  remembering  that  the  chloroform  solution  is  sometimes  a 
painful  application. 

A  watery  solution  of  chloral  hydrate  does  very  well  in  some  old,  slug- 
gish cases,  from  gr.  v. — gr.  xv.  to  the  ounce  of  water. 

Ulcers  on  the  leg,  if  old  and  chronic,  often  improve  at  once  upon  the 
use  of  Martin's  rubber  bandage,  or  Fox's  rubber  tubing,  or  any  other 
species  of  strapping,  while  some  phagedenic  forms  of  ulcer  ought  to  be 
allowed  the  chance  of  benefit  promised  by  the  continuous  submersion 
system  described  at  p.  43.  Chronic  syphilitic  ulcers  with  hard  edges  do 
well  if  their  edges  are  scarified  and  poulticed  at  first.  Ulcers  communi- 
cating with  necrosed  or  carious  bone,  or  with  sinuses  leading  into  joints, 
cannot  be  expected  to  get  well  until  the  deeper-seated  lesions  have  been 
overcome. 


LOCAL   MEASURES  APPLICABLE  TO  SYPHILITIC   LESIOKS   UPON   THE    MUCOUS 

MEMBRAXES.  , 

Great  cleanliness  is  the  first  requisite  in  treating  syphilitic  lesions  of 
mucous  membranes.  The  mouth  must  be  subjected  to  all  the  rules  men- 
tioned in  connection  with  the  hygiene  of  the  mouth  (p.  112),  and  the  use 
of  astringent  mouth-washes,  as  well  as  some  of  the  other  measures  sug- 
gested in  cases  of  salivation  (p.  126),  might  be  called  for.  The  use  of  to- 
bacco must  be  stopped  in  the  case  of  mouth  lesions;  the  vagina  and  vulva 
should  be  syringed  and  washed  frequently  in  the  event  of  lesions  in  this 
quarter;  constipation  must  be  avoided,  and  cleanliness  enjoined  whenever 
the  rectum  is  threatened  with  trouble,  or  becomes  the  actual  seat  of 
lesions. 

Mouth,  lesions  are  the  most  common  and  most  apt  to  be  protracted. 
Steaming  the  throat  and  mouth,  gargles  of  hot  milk,  of  infusion  of  flax- 
seed,  of  warm  tea,  with  or  without  a  little  borax,  gr.  x. — xx.  to  §  i.,  or 
chlorate  of  potash,  gr.  v. — xv.  to  §  i.,  have  an  excellent  soothing  effect  in 
these  cases.  A  certain  amount  of  chlorate  of  potash  should  be  swallowed, 


SYPHILIS.  131 

that,  by  returning  into  the  mouth  in  solution  in  the  saliva,  it  may  keep  up 
a  constant,  mild,  soothing  action  upon  the  various  lesions. 

One  excellent  expedient,  in  cases  where  mouth  lesions  are  constantly 
recurring,  is  to  give  whatever  mercury  may  be  required  for  general  treat- 
ment in  the  form  of  compressed  pills  of  sugar-of-milk  and  bichloride  of 
mercury.  Such  pills  of  varying  strength  are  made  by  Dunton  and  by 
Wyeth.  The  two-milligramme  pill  is  a  good  one  for  general  use.  These 
pills  are  allowed  to  dissolve  slowly  in  the  mouth,  the  saliva  being  swal- 
lowed. In  this  way  the  local  effect  of  a  solution  of  corrosive  sublimate 
upon  the  mouth  lesions  is  obtained  at  the  same  time  with  the  carrying  out 
of  general  treatment.  The  only  objection  to  this  expedient  is  that  the 
taste  of  bichloride,  while  the  pill  is  slowly  dissolving  in  the  mouth,  is  very 
coppery  and  offensive  to  some  patients. 

The  best  local  applications  to  make  upon  syphilitic  mouth  lesions  are 
solutions  of  corrosive  chloride  of  mercury. 

]J.     Hydrarg.  chlorid.  corrosiv gr.  ij. — v. 

Spts.  rect 3  i. 

M. 

To  be  painted  over  the  affected  surfaces  with  a  soft  brush  daily; 

Or,  the  acid  nitrate  of  mercury,  pure,  in  small  quantity,  touched  upon 
the  lesion  twice  a  week; 

Or,  applications  of  the  nitrate  of  silver,  or  of  the  nitrate  of  zinc,  solid 
or  in  solutions  of  varying  strengths; 

Or,  the  daily  use  of  a  solid  lump  of  pure  sulphate  of  copper,  which  is 
to  be  lightly  rubbed  over  the  lesion. 

Mercurial  fumigations  (p.  124)  are  of  the  utmost  value  in  many  forms 
of  mouth  lesion. 

In  cases  of  pure  gummata  of  the  mouth  and  throat,  it  is  best  not  to 
waste  time  with  mercurial  local  applications,  since  attention  in  this  way 
may  be  diverted  from  the  main  Jiope  in  such  cases — the  unsparing  use  of 
the  iodide  of  potassium  internally. 

Upon  the  vulva,  vagina,  beneath  the  prepuce,  and  elsewhere,  the  same 
general  line  of  treatment  is  to  be  followed  as  for  similar  lesions  within  the 
mouth — cleanliness  being  perhaps  of  more  value  than  any  other  one  local 
method  of  treatment.  Pedunculated  condylomata,  or  other  vegetations, 
may  be  snipped  off,  and  the  base  from  which  they  grow  cauterized. 


THE    IODIDES    AND    PREPARATIONS    OF   IODINE. 

Several  of  the  iodides  with  alkaline  bases  hold  a  high  rank  in  the 
treatment  of  syphilis,  especially  of  its  later  symptoms;  and  justly,  for 
the  prompt  effect  produced  upon  certain  symptoms,  especially  where  the 
lesion  is  gummatous,  by  a  free  use  of  the  iodides,  is  often  very  striking. 
To  be  effective,  however,  the  iodides  must  be  used  wisely;  and  it  is  well 
known  what  they  can  do  and  when  they  may  be  trusted. 

Unfortunately,  the  popular  dislike  to  mercury  is  shared  by  many 
physicians;  and  these  gentlemen,  in  looking  around  for  a  specific  for 
syphilis  which  is  not  mercury,  often  fall  upon  the  iodides  and  administer 
them  in  different  vegetable  infusions  and  tinctures  from  the  very  begin- 
ning of  syphilis,  praising  themselves  and  calling  for  the  applause  of 
their  patients  in  that  they  give  no  mercury.  It  is  better,  doubtless,  to 


132  THE    VENEKEAL    DISEASES. 

treat  early  syphilis  -with  iodide  of  potassium,  than  not  to  treat  it  at  all; 
but  exactly  how  much  better,  it  is  hard  to  estimate.  The  iodides  have 
little  power  in  postponing  erruptions,  or  promptly  modifying  them  after 
they  have  appeared  early  in  syphilis.  They  certainly  have  little  or  no 
power  in  preventing  relapse  either  early  or  late  in  the  disease.  I  think 
that  I  brought  out  this  point  satisfactorily  in  the  paper  I  have  already 
alluded  to,  read  before  the  International  Congress  at  Philadelphia,  and 
need  not  reproduce  here  the  line  of  argument  there  followed.  The 
iodides  have  their  place,  and  a  very  important  place  it  is;  but  I  think  it 
unfortunate  that  they  are  accredited  with  much  curative  power  over  syph- 
ilis, since  this  notion  naturally  leads  to  their  abuse,  and  tends  to  bring 
them  into  disrepute. 

Whenever  the  lesion  is  gummatous,  in  most  of  the  intermediary  and 
late  syphilides,  and  whenever  the  proliferative  changes  of  connective  tis- 
sue so  common  in  advanced  syphilis  in  the  internal  organs  are  going  on, 
the  iodide  of  potassium  is  a  power,  and  an  enormous  power,  which  may 
be  used  to  the  great  advantage  of  the  patient,  either  alone  in  very  large 
doses  in  appropriately  selected  cases,  or  in  combination  with  mercury,  in 
more  moderate  doses, — constituting  what  is  known  as  the  mixed  treat- 
ment. 

When,  however,  the  symptoms  for  which  the  iodide  is  used  have  been 
fairly  and  entirely  overcome,  then  the  mercurials  resume  sway,  and  it  is 
better  shortly  to  drop  the  iodides,  holding  them  in  reserve  for  other  emer- 
gencies. 

The  preparations  of  iodine  most  valuable  in  syphilis  are  the  iodides  of 
potassium  and  of  sodium.  The  iodides  of  calcium,  starch,  and  ammonium 
are  also  used,  and  iodine  as  tincture,  simple  and  compound,  and  in  the 
shape  of  iodoform  internally.  I  shall  speak  of  these  last  first,  in  order  to 
dispose  of  them. 

I  have  been  disappointed  in  obtaining  any  marked  effects  from  iodo- 
form internally  given  in  doses  of  a  fraction  of  a  grain  up  to  three  grains 
at  a  time.  I  have  given  a  single  dose  of  half  a  drachm,  but  without 
obvious  effect,  in  a  case  at  the  Charity  Hospital.  I  cannot,  therefore,  from 
personal  experience  recommend  it,  or  give  any  special  indications  for  its 
use.  It  is  spoken  well  of,  however,  in  some  high  quarters,  used  in  rather 
small  doses  in  combating  gummatous  disease — as  of  the  tongue  (Hill). 

The  tincture  of  iodine,  and  the  compound  tincture  in  starch-water 
(forming  the  fresh  iodide  of  starch),  I  have  used  at  times  with  undoubted 
advantage.  It  is  very  dark  to  look  at,  and  not  pleasant  to  the  taste, 
being  flat,  rather  nauseating  than  otherwise;  but  it  is,  on  the  whole,  bland 
and  rather  easily  digested,  and  I  certainly  have  seen  decided  advantage 
follow  its  use  in  cases  where  the  iodides  of  potassium  or  sodium  were  badly 
borne  by  the  stomach.  I  have  usually  commenced  with  the  tinctures  in 
doses  of  ten  drops  in  a  tablespoonful  or  more  of  starch-water,  and  in- 
creased up  to  eighty  drops  in  a  claret-glass  of  the  diluting  fluid.  I  am  not, 
however,  at  all  willing  to  trust  to  the  iodide  of  starch  in  an  emergency. 

The  iodide  of  ammonium  is  generally  used  in  combination  with  other 
iodides,  under  the  idea  advanced  by  Paget  and  sustained  by  Hutchinson, 
that  the  carbonate  of  ammonia  given  in  combination  with  the  iodide  of 
potassium  intensified  the  action  of  the  latter.  I  have  not  used  the  iodide 
of  ammonium  alone  in  large  doses. 

The  iodides  of  potassium  and  of  sodium  hold  the  first  rank  among  the 
preparations  of  iodine  as  specifics  against  syphilitic  gummata.  Of  these 
the  first-named  is  the  more  powerful,  but  it  has  the  disadvantage  of  be- 


133 

ing  decidedly  more  irritating  to  the  stomach  than  the  iodide  of  sodium. 
Both  of  these  iodides  act  alike,  and  both  are  of  great  value  in  the  treat- 
ment of  syphilis. 

These  iodides,  however,  like  most  other  good  things  in  the  world,  have 
their  own  peculiar  bad  qualities.  Perhaps  not  the  least  of  these  is  the 
fact  that  the  drugs  are  expensive;  while,  unfortunately,  it  is  necessary  to 
use  them  in  large,  often  heroic,  doses.  As  a  consequence,  the  iodides  are 
generally  much  adulterated,  especially  in  the  smaller  shops;  and  the  poor 
man,  who  perhaps  needs  the  drug  more  than  his  more  wealthy  fellow-suf- 
ferer, often  gets  in  his  dose  as  much  bromide  as  he  does  iodide  of  potas- 
sium. 

The  bitter,  coppery  taste  which  the  iodides  produce  in  the  mouth  of 
the  patient  taking  the  drug  in  any  considerable  quantity,  and  most  offen- 
sively tasted  in  the  morning  upon  first  awaking,  is  a  drawback  in  some 
cases  to  the  free  use  of  the  remedy.  Occasionally  the  mouth  is  made 
sore  by  long-continued  use  of  the  iodides,  the  gums  get  tender  and  spongy, 
they  swell  as  in  true  salivation,  and  a  certain  amount  of  soreness  in  the 
teeth  is  complained  of,  together  with  an  increased  flow  of  saliva — the 
whole,  indeed,  forming  a  sort  of  spurious  salivation.  These  two  lesser 
evils  may  be  measurably  abated:  the  first,  by  the  use  of  peppermint  in 
some  form,  both  at  the  time  of  taking  the  dose  and  upon  awaking  in 
the  morning;  the  second,  by  the  use  of  astringent  mouth-washes,  diuretics, 
and  such  remedies  as  are  generally  useful  in  true  salivation. 

Besides  these  lesser  evils  sometimes  attending  the  use  of  the  iodides, 
there  are  five  other  serious  discomforts  which  are  attached  to  their  em- 
ployment: acute  catarrh,  headache,  iodism,  cutaneous  eruptions,  and  irri- 
tation of  the  stomach. 

Acute  catarrh,  to  the  extent  occasionally  of  rendering  the  patient 
very  miserable,  sometimes  comes  on  at  the  very  beginning  of  the  use  of 
the  iodides.  The  patient  sneezes  and  coughs,  the  eyes  grow  red  and 
watery,  the  nose  runs,  and  with  this  sometimes  comes  an  intense  pain 
across  the  brow,  and  perhaps  severe  headache.  This  symptom,  like  most 
of  the  others  due  to  the  iodides,  varies  in  intensity  with  the  strength  of 
the  dose.  Unlike  some  of  the  other  symptoms,  it  often  wears  off  as  the 
iodide  is  continued  in  use,  or  at  least  the  patient  gets  accustomed  to  it 
and  complains  less. 

The  treatment  of  this  catarrh  is  to  keep  the  skin  active  by  the  use  of 
warm  baths,  to  give  the  patient  plenty  of  bland  fluids  to  drink,  and  to 
encourage  the  action  of  the  kidneys,  the  proper  channels  of  exit  for  the 
iodides.  Belladonna  internally,  in  small  quantities,  has  a  certain  amount 
of  influence  in  controlling  the  amount  of  secretion  from  the  nose  and 
throat. 

The  headache  produced  in  some  people  by  the  use  of  the  iodides  is 
quite  intense.  It  usually  occupies  the  brow,  or  the  side  or  the  whole  top 
of  the  head.  The  headache  comes  on  sometimes  after  a  single  dose  of 
the  offending  drug,  and  sometimes  is  so  intense  that  it  constitutes  a  posi- 
tive bar  to  the  continued  use  of  the  remedy.  Fortunately,  cases  of  this 
sort  are  quite  rare. 

The  only  treatment,  so  far  as  I  know,  able  to  remedy  this  condition,  is 
to  give  a  mild  diuretic  in  combination  with  the  iodide,  and  to  add  some 
of  the  bromide  of  potassium  to  the  mixture,  or  even  a  little  opium.  Fortu- 
nately, this  idiosyncrasy  of  having  headache  when  taking  the  iodides  is 
not  always  an  affair  of  a  lifetime;  the  patient  generally  outgrows  it  in 
time. 


134  THE    VENEREAL   DISEASES. 

Iodism,  properly  speaking,  includes  the  headache  and  catarrh  already 
alluded  to;  but  the  main  feature  in  iodism  proper  is  a  peculiar  and  intense 
nervous  depression,  with  irritability.  This  occurs  in  certain  individuals 
when  they  take  the  iodides.  With  this  depression  there  may  be  more  or 
less  ringing  in  the  ears,  pain  in  the  bones,  etc. 

Iodism  is  difficult  to  overcome  by  treatment;  usually  all  efforts  fail. 
The  general  means  mentioned  above  for  the  headache  of  iodine  may  also 
be  tried  here. 

The  cutaneous  eruptions  produced  by  the  iodides  are  numerous. 
Erythema,  with  considerable  scaling  of  the  skin,  and  acne,  with  boils 
about  the  face,  nose,  neck,  back,  shoulders,  and  buttocks,  are  not  uncom- 
mon results  of  their  use.  Purpura  hfemorrhagica  is  produced  by  the 
iodides,  especially  in  debilitated,  anaemic  persons  who  have  taken  the  drug 
for  a  long  time.  A  peculiar  form  of  pemphigoid  eruption  occurring  in 
groups,  and  sometimes  called  hydroa  (Hutchinson),  is  another  of  the  evil 
results  of  the  iodides  upon  the  skin  of  some  patients. 

The  irritation  produced  in  the  stomach,  and  sometimes  in  the  in- 
testine by  the  iodides,  especially  when  used  in  large  doses,  is  another  seri- 
ously bad  quality  which  they  possess.  In  this  way  nausea  and  lack  of 
appetite  may  be  induced,  going  on,  sometimes,  to  diarrhoea,  and  leading 
to  anaemia  and  loss  of  strength — misfortunes  which,  by  so  much,  go  to 
counteract  the  good  effects  produced  by  the  drugs. 

This  irritation  of  the  stomach  and  skin  attaches  often  to  an  imperfect 
elimination  of  the  drug  by  the  kidneys.  When  a  patient  is  under  full 
doses  of  the  iodides,  his  urine  is  full  of  them,  as  may  be  demonstrated  by 
pouring  a  little  nitric  acid  into  a  test-tube  containing  some  of  the  urine. 
The  stronger  acid  attacks  the  salt  and  liberates  the  iodine,  which  colors 
the  urine,  lying  above  the  layer  of  acid.  If  the  kidneys  do  not  do  their 
duty  properly,  some  of  the  cutaneous  expansions  of  the  body  must  suffer: 
it  may  be  the  membrane  of  the  nose;  it  may  be  the  skin  of  the  face  or 
back,  or  the  glands  this  skin  contains;  or  it  may  be  the  stomach.  The 
stomach  is  also  particularly  exposed  to  irritation  by  direct  contact  with 
the  medicine.  This  direct  contact  the  stomach  always  resents,  especially 
if  the  drug  be  presented  to  it  in  a  concentrated  form,  when  it  is  empty. 

The  natural  deduction'from  all  this  is  that  the  kidneys  must  be  kept 
always  active,  when  the  iodides  are  being  administered,  by  the  use  of 
plenty  of  water  and  bland  fluids  on  the  part  of  the  patient,  as  well  as  by 
diluting  the  drug  largely  when  it  is  taken,  and  giving  it  always  upon  a 
full  stomach.  If  these  means  do  not  suffice,  the  dose  of  the  iodide  may 
be  combined  with  a  more  active  diuretic — such  as  the  acetate  of  potash, 
or  the  infusion  of  digitalis,  or  both. 

Sometimes,  in  spite  of  all  precautions,  the  iodides  cannot  be  taken  by 
the  stomach.  Under  such  circumstances  I  have  sometimes  succeeded  in 
using  the  rectum,  giving  ten  and  fifteen  grain  doses  of  the  iodide  of  so- 
dium dissolved  in  an  ounce  of  warm  beef-tea.  I  have  tried  iodoform  in 
suppository — gr.  vi.  at  a  dose — but  have  failed  to  get  any  good  systemic 
effect  from  the  latter  drug.  When  the  stomach  fails,  the  iodide  of  starch 
may  often  be  borne,  and  should  have  a  trial. 

Above  all,  it  must  be  borne  in  mind  that  the  iodides  should  never  be 
given  solid  (in  pill  form)  when  their  use  in  large  quantities  is  required. 
Small  doses  in  pill  form  do  very  well  in  some  cases,  as  high  as  gr.  v.  of 
the  iodide  in  each  pill;  but  such  pills  should  only  be  given  upon  a  full 
stomach,  or,  perhaps  better,  taken  during  the  middle  of  a  meal. 

When  it  becomes  absolutely  necessary  to  push  the  iodides,  it  should 


SYPHILIS.  135 

be  done  in  spite  of  all  obstacles  to  the  contrary.  I  succeeded,  in  one  such 
case,  in  arresting  a  destructive  gummatous  ulcer  by  confining  my  patient 
exclusively  to  boiled  milk  and  rice  as  food,  and  giving  bismuth  inconsid- 
erable quantities,  while  the  iodide  was  being  pushed.  The  addition  of 
opium,  or  anything  else  to  make  the  drug  act,  is  allowable  under  these 
circumstances. 

The  dose  of  the  iodides  is  about  five  grains,  to  commence  with  in  an 
ordinary,  ijntried  case,  where  the  effect  of  the  drug  has  never  been  tested, 
and  when  there  is  no  emergency  to  deal  with.  This  five-grain  dose  will 
generally  indicate  in  what  way,  if  at  all,  the  patient  is  to  be  uncomfortably 
affected  by  the  iodides.  An  occasional  pimple  of  acne  on  the  forehead 
or  temple  is  generally  all  that  will  be  seen,  with  perhaps  a  little  excess  of 
secretion  from  the  mucous  membrane  of  the  nose  during  the  first  few 
days  of  the  course.  For  an  ordinary  case,  where  there  is  no  haste  and 
the  stomach  is  to  be  respected,  the  dose  of  the  iodide  may  be  pushed  by 
an  increase  of  two  and  a  half  grains  in  the  dose  each  week.  By  such  a 
gradual  increase,  with  a  little  care,  the  stomach  need  not  be  injured,  the 
skin  is  not  apt  to  give  much  trouble,  and  the  weekly  increase  in  the  dose 
may  be  suspended  when  the  symptoms  have  fairly  yielded. 

No  such  caution,  however,  can  be  indulged  in  when  an  emergency  is 
at  hand.  When  the  soft  palate  is  threatened  with  rapid  destruction  by  a 
perforating  gummy  ulcer,  when  the  bones  of  the  nose  are  crackling  under 
the  touch,  when  the  functions  of  the  brain  are  involved  or  life  threatened, 
then  there  is  no  time  for  hesitation  or  delay,  and  it  is  not  necessary  to 
ask  whether  the  iodide  will  agree  or  not.  If  it  does  not  agree,  it  must  be 
made  to  agree — a  process  which  may  tax  the  resources,  the  ingenuity,  and 
the  patience  of  the  surgeon  to  the  utmost.  Under  such  circumstances,  a 
dose  of  ten  grains  every  four  hours  is  a  moderate  beginning,  and  in  one 
or  two  days,  according  to  the  surgeon's  judgment  and  the  patient's  neces- 
sities, the  dose  ma}'  be  increased  by  five  or  ten  grains,  and  so  on,  indefi- 
nitely, until  the  symptoms  yield  or  the  stomach  refuses  to  receive  the 
drug. 

In  such  a  case  the  stomach  must  be  managed  with  all  care  in  the  man- 
ner suggested  above,  and  opium,  if  need  be,  bromides,  or  diuretics,  with 
bland  food,  judiciously  joined  to  the  iodides  in  such  a  way  that  the  stom- 
ach shall  have  no  excuse  for  rebellion.  Limit  to  the  dose  there  is  none: 
the  signal  to  stop  increasing  the  dose  in  a  desperate  case  is  unconditional 
surrender  on  the  part  of  the  symptoms.  If  the  diagnosis  has  been  accu- 
rate and  the  stomach  can  be  managed,  this  result  will  follow  as  surely  as 
the  night  follows  day.  The  physician  need  have  no  fear,  there  need  be 
no  hesitation.  If  the  stomach  holds  out,  and  the  drug  is  boldly  and  intel- 
ligently pushed,  victory  is  the  one  and  only  result.  All  minor  symptoms 
of  iodism  may  be  disregarded,  the  eruptive  troubles,  the  catarrh,  even  the 
headache  and  depression  of  spirits,  although  these  last  make  some  patients 
desperate,  so  that  they  seem  rather  willing  to  suffer  anything  from  the 
disease  than  to  be  compelled  to  continue  their  medicine. 

The  limit  to  the  dose  which  may  be  given  I  do  not  know.  It  is  cer- 
tain that  more  than  an  ounce  of  the  solid  salt  has  been  taken  daily  by  a 
single  patient,  and  continued  a  number  of  days  with  advantage,  and  this 
has  been  done  a  number  of  times  in  various  cases  by  different  physicians. 
It  is  rarely  necessary,  however,  even  in  the  most  desperate  cases,  to  go 
higher  than  three  or  fotir  drachms  a  day;  and  such  a  quantity  is  better  in 
its  results  if  administered  in  six  than  in  three  doses,  always  well  diluted 
with  water. 


136  THE    VENEREAL   DISEASES. 

When  small  quantities  are  to  be  given  for  a  considerable  time,  and 
the  stomach  has  been  first  tested  with  a  solution  to  try  its  temper,  the 
medicine  may  be  given  in  pill  form  for  the  sake  of  convenience.  It  is  not 
easy  to  make  good  pills  out  of  the  iodide  of  potassium,  on  account  of  the 
tendency  they  have  to  become  moist  by  contact  with  the  atmosphere,  to 
stick  together  and  disintegrate.  Pills  of  varied  strength  up  to  five  grains 
of  the  pure  iodide  of  potassium  are  now  found  in  the  shops  in  the  com- 
pressed form.  They  bear  transportation  well  if  kept  in  bottles  stoppered 
with  a  cork.  To  make  up  a  pill,  however,  of  any  strength,  a  little  pep- 
per, gum  tragacanth,  and  glycerine  make  excellent  excipients.  Such  a 
pill  when  well  made  grows  solid,  smooth,  and  quite  hard;  but  its  hardness 
is  no  obstacle  to  its  digestion,  since  the  affinity  of  the  iodides  for  water 
is  very  great,  and  such  pills  readily  break  up  in  the  stomach.  A  fair  for- 
mula is  the  following  : 

$ .     Potassiii  odidi 3  i j. 

Pulv.  pip.  nig 3  i. 

Gum  tragacanth   ) 

Glycerinae  j *"    ' 

M.  Ft.  pil.  no.  xxiv. 

These  pills  are  not  unnaturally  large,  each  one  contains  five  grains  of 
the  iodide,  and  they  should  be  taken  with  or  immediately  after  each  meal. 
In  many  cases  they  do  not  disagree,  in  others  they  certainly  do. 

A  favorite  method  of  giving  the  iodides  is  in  combination  with  some 
bitter  vegetable  tincture  or  infusion,  which  serves  the  double  purpose  of 
masking  the  peculiarly  pungent,  bitter  taste  of  the  drug,  as  well  as  in  a 
measure  assisting  its  digestion.  The  taste  of  the  iodide  may  be  still  further 
covered  up  by  the  addition  of  ginger,  peppermint,  or  bitter  orange,  to  the 
solutions  in  one  form  or  another,  and  the  dose  thus  made  actually  agreea- 
ble. Some  ammonia  may  be  added,  if  thought  best,  out  of  respect  to  the 
general  conviction  that  the  presence  of  this  drug  enhances  the  therapeu- 
tical activity  of  the  iodide.  Such  a  formula  as  the  following  is  rarely  ob- 
jected to : 

IJ  •     Potass,  iodid 3  i  j. 

Ammonias  subcarb 3  ss. 

Tr.  cinchonas  co 3  iv. 

Glycerinae 3  i. 

Syr.  aurantii  cort §  iss. 

M.  3 
S.  Teaspoonful  largely  diluted  with  water  after  each  meal. 

For  convenience  of  administration,  where  the  dose  of  iodide  is  to  be 
constantly  and  rapidly  push'ed,  it  is  well  for  the  patient  to  have  two  pre- 
scriptions: one  something  like  the  one  given  above,  and  another  a  satu- 
rated solution  of  the  iodide  of  potassium  in  distilled  water: 

$,  •     Potass,  iodidi §  i. 

Aquas  destillatae q.  s.  ad  fl.  ^  i- 

M. 

Of  this  solution  one  minim  measured  in  a  minim-glass  represents  a 
grain  of  the  iodide  of  potassium,  and  it  may  be  very  conveniently  used, 


SYPHILIS.  137 

a  teaspoonful  of  the  pleasantly  tasting  mixture  being  mingled  with 
water,  and  as  many  minims  extra  of  the  saturated  solution  of  the  iodide 
being  added  to  each  dose  as  may  be  required  to  make  the  dose  of  the 
iodide  sufficient,  in  cases  where  this  is  varied  a  little  from  day  to  day. 

It  will  be  noticed  in  the  foregoing  prescription  that  only  enough 
water  is  ordered  to  make  an  ounce  of  fluid  in  all.  As  commonly  writ 
ten,  the  prescription  reads: 

3 .     Potassii  iodidi f  i. 

Aquse  destillatas §  i. 

M. 

Such  a  formula  makes  more  than  an  ounce  of  fluid — nearly  an  ounce 
and  a  half,  in  fact — and  it  takes  about  seven  minims  to  equal  five  grains 
of  the  iodide  of  potassium. 

All  the  remarks  thus  far  made  have  referred  to  the  iodide  of  potas- 
sium, nothing  having  been  said  of  the  iodide  of  sodium.  The  potassium 
compound  is  the  stronger,  being  just  about  twice  as  effective  as  the  so- 
dium combination.  It  is  therefore  to  be  preferred,  and  in  all  cases 
should  be  commenced  with  first.  When,  after  fair  trial  and  reasonable 
effort,  it  has  become  apparent  that  the  potassium  iodide  is  not  suitable, 
and  that  the  stomach  will  not  bear  it,  then  the  sodium  iodide  may  be 
substituted,  often  with  very  good  effect,  since  in  this,  as  in  many  other 
cases,  the  soda  salt  is  more  comforting  to  the  stomach  than  the  potash 
salt.  All  that  has  been  written,  therefore,  concerning  the  iodide  of 
potassium  is  equally  applicable  to  the  iodide  of  sodium  for  those  cases  in 
which  the  stronger  drug  is  not  well  borne. 


'MIXED    TREATMENT. 

The  mixed  treatment  is  a  combination  of  one  of  the  iodides  with  a 
mercurial.  It  is  one  of  the  commonest  forms  of  treatment,  and  one  of 
the  most  useful,  when  intelligently  directed.  It  is  of  no  value  at  the 
beginning  of  the  disease.  The  over-zealous  young  practitioner,  in  his 
early  efforts  to  do  all  he  can  for  his  patient,  is  quite  apt  to  overshoot  the 
mark  in  trying  to  obtain  for  his  patient  all  the  good  possible  out  of  all 
kinds  of  medicine.  He  frequently  gives  the  mixed  treatment  (mercury 
and  potash,  as  he  commonly  calls  it,  instead  of  mercury  and  iodine, 
which  it  more  properly  is),  ordering  it  as  soon  as  he  decides  that  a  given 
chancre  is  syphilitic. 

There  is  no  advantage  in  such  a  course.  Mercury  is  all-sufficient  in 
the  beginning,  and  anything  like  polypharmacy  is  of  doubtful  wisdom, 
since  the  stomach  and  its  integrity  constitute  the  sheet-anchor  of  the 
syphilitic  patient  in  the  long  run.  He  may  have  much  medication  to 
endure,  and  it  is  well  to  spare  him  in  the  beginning.  Many  stomachs 
submit  to  the  prolonged  use  of  the  iodides  without  a  murmur,  for  years; 
but  there  are  others  which  gradually  fail  in  digestive  capacity,  and  reduce 
the  patient  to  a  condition  of  anaemia,  with  great  general  nervous  irrita- 
bility and  prostration,  and  that,  too,  without  giving  rise  to  any  marked 
active  evidences  of  dyspepsia.  The  iodides,  long  continued,  are  fully  as 
apt,  or  more  apt,  I  think,  to  do  harm  than  the  mercurials.  It  may  be- 
come necessary,  during  a  prolonged  and  obstinate  attack  of  syphilis,  to 


138  THE   VENEREAL   DISEASES. 

use  not  only  the  mercurials  for  a  long1  time,  but  the  iodides  also;  and 
when  it  becomes  necessary,  let  it  be  done.  But  this  is  not  an  excuse  for 
using  the  iodides  out  of  place,  or  calling  upon  the  stomach  for  extra 
work  where  it  is  not  required. 

The  mixed  treatment  is  appropriate  in  all  the  slower,  more  chronic 
symptoms  of  the  intermediary  and  late  stages  of  syphilis.  The  basis  of 
the  treatment  is  an  appropriate  iodide,  either  of  sodium  or  of  potassium, 
as  the  case  may  be,  and  with  it  a  mercurial.  The  treatment  may  be 
effectually  carried  out  by  giving  a  suitable  dose  of  the  iodide,  as  directed 
in  the  last  section,  and  adding  the  mercury  by  fumigation,  inunction,  or 
separately  in  pill.  It  is  a  little  more  appropriate,  however,  and  perhaps 
more  accurate  in  dosage  when  giving  the  mixed  treatment,  to  mix  the 
drugs  themselves  in  the  same  pill  or  potion.  The  best  drug  to  mix 
with  the  iodides  is  the  biniodide  of  mercury.  Most  other  forms  decom- 
pose, and  the  resulting  compound  is  an  uncertain  amount  of  biniodide  of 
mercury  with  an  equally  uncertain  quantity  of  the  other  mercurial,  how- 
ever much  there  may  be  which  has  escaped  decomposition. 

The  biniodide  of  mercury,  therefore,  may  be  added  to  any  of  the  pills 
or  fluids  already  referred  to  in  the  section  on  the  iodides,  in  a  dose  vary- 
ing from  one-thirtieth  up  to  a  tenth  of  a  grain.  The  new  ingredient  in 
the  combination  will  make  no  difference  in  its  form  or  taste,  but  often 
makes  a  great  difference  in  its  effect  upon  the  patient. 

Some  of  the  compressed  pills  found  in  the  market  are  made  so  as  to 
represent  the  mixed  treatment,  containing  varied  proportions  of  the 
iodide  of  potassium  and  the  biniodide  of  mercury. 

In  using  the  mixed  treatment,  it  is  often  desirable  to  continue  the 
mercury  at  a  given  rate  while  the  iodide  is  steadily  pushed.  This  con- 
stitutes what  is  called  mixed  treatment  with  iodides  in  excess,  an  expres- 
sion which  will  be  found  to  occur  several  times  in  this  book  when  speak- 
ing of  the  treatment  appropriate  to  some  of  the  various  lesions.  Such  a 
treatment  may  be  conveniently  carried  out  by  adopting  a  certain  fixed 
formula  for  the  mixed  treatment,  preferably  one  which  shall  not  be  dis- 
tasteful to  the  patient,  and  furnishing  him  besides  this  with  a  minim- 
glass,  and  a  saturated  solution  of  the  iodide  of  sodium,  or  potassium,  as 
the  case  may  be.  In  this  way  the  dose  may  be  easily  regulated  to  suit 
any  emergency. 

I  find  the  following  to  be  an  excellent  standard  to  use  as  a  base  of 
operations: 

R.     Hydrarg.  biniodidi gr.  ss. — i. 

Potassii  iodidi 3  ij. 

Ammonii  iodidi 3  ss. 

Syr.  aurantii  corticis §  ij. 

Tr.  aurantii  corticis 3  j. 

Aquae  destillatae q.  s.  ad  §  iv. 

M. 
S.  Teaspoonful  well  diluted  in  water  after  each  meal. 

When  to  cease  giving  the  iodides  is  a  question  of  importance. 
They  are  useful,  most  useful,  against  certain  symptoms  in  syphilis,  but 
they  cannot  claim  power  to  prevent  relapse.  Therefore  we" should  use 
them,  and  vigorously  too,  against  those  symptoms  which  they  control, 
but  should  not  depend  upon  them  for  any  more  work  after  the  symptoms 


SYPHILIS.  139 

have  yielded.  The  main  difficulty  in  the  case  is,  therefore,  how  to  tell 
when  the  symptoms  in  question  are  thoroughly  controlled.  A  gumma- 
tous  infiltrated  patch  may  gradually  melt  away  under  the  bold  use  of  the 
iodides,  and  seem  to  be  entirely  gone;  yet,  if  the  iodides  be  discontinued 
too  soon,  this  patch  will  relapse  in  many  cases.  How  can  it  be,  then,  that 
the  iodides  do  not  prevent  relapse  ? 

I  think  that  the  answer  to  this  question  may  be  found  by  analogy  in 
the  study  of  other  infiltrations.  Gummatous  processes  are  infiltrations, 
and  the  tertiary  connective-tissue  proliferations,  the  parenchymatous  hy- 
pertrophy of  organs,  is  an  analogous  change.  These  diseased  conditions 
of  the  tissues  extend  farther  than  is  evident  to  the  naked  eye.  In  the 
same  way  cancerous  infiltrations  and  epitheliomatous  nodules  far  outreach 
their  limits  as  apparent  to  ordinary  inspection.  An  epithelioma  may  be 
burned  upon  the  surface,  and  the  nodule  apparently  destroyed — so  much, 
indeed,  that  a  thin,  unhealthy  scar  may  form  over  the  spot;  yet  the  mor- 
bid tissue,  although  apparently  all  gone,  often  remains  in  the  outlying  tis- 
sues, and  in  such  a  case  local  relapse  is  inevitable.  The  same  is  true  of 
lupus,  and  the  effect  of  local  applications  upon  it;  and  of  carcinoma,  and 
the  cutting  operations  to  which  it  is  subjected. 

In  the  same  way  with  syphilitic  infiltrations:  the  remedy  which  removes 
them,  the  iodic  preparations,  must  be  long  and  patiently  continued  after 
the  local  trouble  is  apparently  under  control,  or  local  relapse  is  certain. 
It  is  customary,  therefore,  to  continue  the  mixed  treatment  for  months 
after  all  evident  need  for  the  iodides  has  passed,  and  then  gradually  to 
drop  the  iodides  and  resume  the  mercurial  at  the  tonic  dose.  Eventually 
the  mercury  itself  may  be  gradually  dropped  after  a  number  of  months, 
differing  in  varying  cases,  according  to  the  judgment  of  the  physician. 

In  some  cases  of  old  syphilis,  especially  the  nervous  forms,  where  the 
iodides  have  been  long  given  in  large  doses,  the  symptoms  may,  after  a 
time,  fail  to  yield  to  the  drug,  while  the  patient  gradually  grows  thin, 
nervous  in  the  ordinary  sense  of  the  term,  tremulous  perhaps  in  his  move- 
ments, unable  to  sleep,  to  digest  food,  to  perform  mental  work.  I  have 
treated  one  such  case,  where  the  patient  finally  became  unable  even  to 
sign  his  name  so  that  the  writing  would  not  be  questioned,  while  yet 
some  of  the  symptoms  of  nervous  syphilis  were  still  upon  him. 

In  such  a  case,  specific  treatment,  so  called,  loses  its  value.  The  pa- 
tient I  allude  to  above  got  perfectly  well  by  dropping  his  specifics  entire- 
ly, taking  the  hypophosphites,  giving  up  work,  and  going  to  the  country 
for  several  months.  He  became  well,  and  has  remained  so  for  the  past 
two  years,  although  just  before  leaving  off  his  treatment  he  had  had  gum- 
matous  deposit  within  the  orbit,  with  paralysis  of  the  internal  rectus. 
Another  patient,  totally  incapacitated  for  work  by  a  prolonged  treatment 
with  the  iodides,  on  account  of  serious  syphilitic  cerebral  symptoms,  re- 
covered entirely  upon  leaving  off  all  medication,  and  going  to  the  dry  cure 
in  Lindeweisse,  in  Austrian  Silesia,  for  six  weeks. 

Such  patients  sometimes  get  well  under  the  homoeopathic  cure  (i.  e., 
without  medicine),  or  by  syphilization,  or  by  going  to  one  mineral  spring 
or  another,  or  (quite  often)  in  water-cure  establishments.  These  patients 
are  very  appropriate  for  a  course  at  the  hot  springs. 

The  main  difficulty  in  the  case  of  patients  of  this  sort  is  to  determine 
just  at  what  time  they  may  safely  give  up  the  use  of  the  iodides.  They 
are  a  source  of  great  solicitude  to  the  physician  in  charge,  and  his  best 
judgment  is  seriously  taxed  in  their  management. 

For  these  cases,  tonics,  change  of  residence,  freedom  from  annoyance 


140  THE    VENEREAL   DISEASES. 

and  from  mental  work  or  worry,  are  essential;  and  a  course  at  some  of 
the  hot  mineral  springs,  or  at  a  water-cure  establishment,  is  often  of  the 
greatest  value. 

ZITTMAN'S  DECOCTION. 

In  terminating  the  general  remarks  upon  the  routine  treatment  of 
syphilis,  something  must  be  said  about  Zittman's  decoction.  This  remedy 
has  long  held  a  respectable  place  in  the  minds  of  the  profession,  and  the 
formula  by  which  it  is  prepared,  in  a  stronger  and  a  weaker  decoction, 
retains  its  place  in  the  dispensatories.  It  is  a  remedy  of  undoubted  value 
in  many  conditions  of  late  syphilis  attended  by  cachexia,  loss  of  appetite, 
anaemia,  and  irritable  stomach,  especially  when  the  iodides  disagree.  Its 
action  is  probably  largely  dependent  upon  the  laxative  influence  of  the 
senna  which  it  contains,  and  upon  the  general  combination  which  makes 
the  mercury  in  it  acceptable  to  the  stomach. 

There  have  always  existed  two  great  drawbacks  to  its  general  use:  (1) 
it  is  difficult  to  prepare,  containing  a  host  of  ingredients  which  must  be 
so  concocted  that  much  time  is  consumed  in  their  proper  preparation; 
and  (2)  its  use  according  to  the  rules  formerly  laid  down  is  too  irksome 
to  be  endured  by  most  patients,  while  the  quantities  necessary  to  produce 
any  effect  (a  pint  and  more  a  day)  cannot  be  conveniently  mastered  by 
many  patients  with  delicate  stomachs.  Then,  also,  the  rules  about  prepara- 
tory purgation,  rest  in  bed,  hot  water  with  one  decoction  at  one  time  in 
the  day,  and  cold  water  with  another  decoction  at  another  time  of  day, 
smack  really  more  of  the  wizzard  than  of  the  sage,  and  tend  to  bring  the 
remedy  into  disrepute  with  honest-minded  persons,  lay  as  well  as  profes- 
sional. 

The  truth  is  probably  that  judicious  purgation,  with  a  light  tonic 
purge  containing  a  mercurial,  and  that  too  in  fair  dose,  is  what  does  the 
good.  In  McDonnell's  lectures  on  surgery  in  1871, l  I  noticed  a  modified 
Zittman's  decoction  which  did  away  with  much  of  the  apparent  nonsense 
of  the  older  preparation.  This  I  used  for  a  time,  but,  finding  even  this 
too  clumsy,  with  its  larger  and  smaller  dose,  and  cold  and  hot  water,  I 
have  reduced  it  to  a  single  combination,  from  which  in  many  cases  I  have 
derived  great  advantage.  I  generally  order  a  teaspoonful  as  a  dose,  to 
be  taken  as  it  is  without  water,  three  or  four  times  daily,  regulating  the 
quantity  by  the  purgative  effect.  The  following  is  the  formula  I  employ : 

IJ.     Hydrarg.  chlorid.  corrosiv gr.  i. 

Aluminis 3  ss. 

Extr.  sarsse fl.  §  ij. 

Glycerinae §  i. 

Syr.  sennae |  iss. 

Spts.  anis 3  i. 

Extr.  glycyrrhizae 3  i. 

Aquae  foeniculi q.  s.  ad  §  viij. 

M. 

S.  Tablespoonful  at  a  dose. 
In  my  hands  it  has  answered  as  well  as  the  original  formula. 

1  Page  114. 


SYPHILIS.  141 

Lockwood,  in  the  London  Lancet,  1879,  gives  two  cases  illustrating 
the  good  effect  upon  obstinate  syphilis,  of  injecting  one-sixth  of  a  grain 
of  nitrate  of  pilocarpin  under  the  skin  every  other  day,  in  combination  (in 
the  worst  case)  with  a  continuance  of  mercurial  treatment,  which  until 
then  had  not  been  effective.  Piffard,  of  New  York,  has  suggested  the 
same  idea. 

The  treatment  of  inherited  syphilis,  and  of  syphilitic  women  during 
pregnancy,  will  be  given  under  their  own  sections. 


CHAPTER  VIII. 

SYPHILIS  OF  THE  SKIN. 

Special  Characters  of  the  Syphilides :  Polymorphism,  Color,  Form,  Absence  of  S  ab- 
jective Symptoms. — Characters  of  Scabs,  Ulcers,  Cicatrices  in  Sj'philis. — The 
Syphilides :  Erythematous,  Papular,  Pustular.  Ecthymatous,  Pigmentary,  Vesic- 
ular, Squamous  (Circinate,  Palmar  and  Plantar),  Tubercular  (General,  in  Groups). 
— Tertiary  Syphilides. — Rupia. — Tertiary  Pustular  Syphilide. — Ecthyma. — Pustu- 
lar Syphilide  in  Groups. — Tertiary  Syphilitic  Ulceration. — Gumma  of  the  Skin. 

SYPHILIS  appeals  to  the  public  and  to  the  patient  most  strongly  through 
its  effects  upon  the  skin.  The  temporary  or  possible  permanent  disfig- 
urement caused  by  it  upon  the  outside  envelope  is  what  lends  it  most  of 
its  horror  in  the  mind  of  the  ordinary  patient.  The  more  serious  affec- 
tions occurring  later  have  no  terrors  for  those  who  ignore  their  existence; 
and  generally  the  patient,  once  free  from  his  symptoms  of  the  skin  and 
mucous  membranes,  considers  himself  well,  and,  often  to  his  cost,  stops 
his  medical  treatment  under  the  idea  that  his  malady  has  ceased  to  exist. 

The  symptoms  upon  the  skin  and  mucous  membranes  have  also  given 
the  physician  his  best  field  for  studying  syphilis;  and  since  the  dermatol- 
ogist has  brought  his  powers  to  bear  upon  a  study  of  the  numerous  le- 
sions of  the  skin  produced  by  syphilis,  much  peculiarity  has  been  found 
to  exist  in  all  the  lesions  due  to  the  disease,  and  much  distinctiveness  in 
form,  color,  grouping,  etc.,  so  that  the  class  of  eruptions  produced  upon 
the  skin  by  syphilis,  and  known  as  syphilides  (Biett),  has  come  to  be  quite 
well  known.  The  syphilides  are  generally  capable  of  being  diagnosti- 
cated by  the  aid  of  simple  inspection.  A  good  clinical  student  of  syph- 
ilis can  usually  do  this  without  asking  a  single  question  or  touching  the 
patient;  and  although  it  is  not  wise  to  jump  at  a  diagnosis,  yet  the  fact 
that  it  is  possible  to  do  this  makes  it  at  once  evident  that  all  the  eruptions 
due  to  syphilis  must  be  possessed  of  some  very  marked  characters,  capa- 
ble of  easy  detection  and  distinguishing  them  from  other  eruptions.  This 
is  the  case,  and  before  going  into  the  detail  of  description  of  the  different 
eruptions  it  will  be  well  to  consider  the  general  characters  which  are 
shared  by  them  in  common. 

Certain  effects  are  produced  upon  the  skin  by  syphilis  which  are  not 
at  all  peculiar  to  the  disease,  but  may  be  just  as  well  produced  by  other 
causes,  and  these  effects  naturally  do  not  share  in  the  general  peculiari- 
ties belonging  to  lesions  due  exclusively  to  the  effect  of  the  syphilitic 
virus.  The  changes  in  the  skin  referred  to  are  the  sallowness,  the  branny 
condition,  the  lack  of  lustre  in  early  syphilis,  the  flabbiness  in  cachexia, 
the  general  tawny  hue  often  seen  in  the  same  stage,  the  seborrhrea,  the 
dryness — none  of  these  features  found  upon  a  syphilitic  patient  differ 
materially  from  the  same  conditions  when  encountered  upon  a  patient 
rendered  ill  by  the  action  of  some  other  debilitating  cause.  They,  there- 


SYPHILIS    OF   THE    SKIN.  143 

fore,  are  not  peculiar,  are  not  to  be  diagnosticated  by  inspection — indeed, 
are  not  syphilitic,  except  in  that  they  have  become  so  by  accident. 

The  peculiar  characters  of  syphilitic  lesions  of  the  integument — those 
•which  they  possess  collectively  as  a  group  of  affections — maybe  best  stud- 
ied by  examining  them  in  detail.  They  are  polymorphism,  color,  form, 
and  the  absence  of  subjective  symptoms  in  connection  with  them;  the 
grouping  of  the  lesions,  the  characters  of  the  scabs  and  ulcers,  arid  the 
appearance  and  behavior  of  the  cicatrices. 

Polymorphism  is  quite  a  distinctive  feature  in  the  early  syphilitic 
exanthemata.  Generally,  it  is  supposed  that  a  cutaneous  eruption  will 
be  uniform  in  the  type  of  its  lesion.  It  is  expected  to  be  purely  erythema- 
tous,  going  on  to  the  formation  of  scales  (roseola  autumnalis),  or  pustular 
preceding  scabs  (impetigo),  or  vesicular  terminating  in  an  oozing  surface 
(eczema);  but  this  does  not  hold  fora  syphilitic  exanthem.  The  evolution 
of  the  syphilitic  eruption  is  in  successive  crops  of  lesions,  and  some  of  these 
go  on  to  a  fuller  development  than  others;  therefore,  in  one  and  the  same 
syphilitic  eruption,  at  almost  any  period  in  its  course,  it  is  often  possible 
to  find  the  most  varied  lesions  associated  side  by  side:  the  macule,  the 
papule,  the  vesicle,  the  pustule,  the  scale,  and  the  pigment  spot. 

Polymorphism  does  occur  in  other  cutaneous  diseases,  but  it  is  so  con- 
stant in  the  syphilitic  exanthemata  as  to  be  worthy  of  special  remark. 
The  same  morbid  spot  upon  the  skin,  in  going  through  its  evolution,  assumes 
the  form  of  several  lesions;  but,  in  the  general  eruption,  there  is  always 
an  excess  of  one  lesion  or  another,  and  this  type  lesion  names  the  erup- 
tion, causing  it  to  be  called  after  its  name — (papular,  pustular,  vesicular, 
etc.,  syphilide). 

Color. — The  color  of  syphilitic  eruptions  is  peculiar.  The  earlier  and 
more  acute  eruptions  are  pink  and  red,  a  color  much  like  that  seen  in 
ordinary  inflammatory  states.  As  the  freshness  dies  out  of  these  erup- 
tions, however,  they  assume  the  syphilitic  tint,  and,  in  some  instances, 
they  possess  it  from  the  start.  This  tint  is  simply  a  certain  lividity  min- 
gled with  red.  It  has  been  called  by  many  names,  but  that  which  suits 
it  best  is  the  raw  ham  color.  Swediaur's  term,  copper  color,  has  taken  a 
greater  hold  upon  the  profession,  but  is  less  accurate  in  expressing  the 
tint  of  syphilitic  lesions  in  their  period  of  activity.  The  copper  color  is 
found  to  perfection  in  many  of  the  lesions  after  they  become  pigmented, 
and  it  often  remains  for  a  long  time  in  scars  left  by  lesions,  and  in  the 
areolar  border  of  the  latter. 

The  color  is  not  due  to  the  syphilitic  poison,  but  to  the  subacute,  or 
indeed,  chronic  quality  of  the  inflammatory  process  which  produces  and 
attends  the  lesions.  The  superficial  vessels  become  dilated,  and  continue 
so  over  circumscribed  areas  for  a  considerable  period.  A  certain  number 
of  red  blood-cells  wander  out  into  the  tissues  through  the  walls  of  these 
vessels,  and  these  cells,  while  passing  through  the  changes  which  precede 
their  absorption,  give  up  their  coloring  matter,  which  becomes  modified, 
and  the  pigment  deposits  and  shows  through. 

This  congestion  and  small  amount  of  pigment  makes  the  raw  ham 
color.  It  is  rarely  absent  in  any  of  the  syphilides.  As  the  congestion 
goes  down  and  the  vessels  return  to  their  natural  size,  the  pigment  be- 
comes more  obvious,  and  then  the  copper  color  appears.  Finally,  nothing 
is  left  but  pigment  in  greater  or  less  quantity,  and  the  color  may  be  that 
of  bronze. 

These  shades  of  color  are  found  exactly  copied  in  some  forms  of  psoria- 
sis, in  certain  chronic  eruptions  on  the  skins  of  gouty  people,  in  eruptions 


144  THE   VENEREAL   DISEASES. 

on  the  legs  of  many  persons  neither  gouty  nor  syphilitic,  in  many  cachec- 
tic conditions,  and  upon  certain  dark  skins  with  almost  any  eruption. 
On  the  other  hand,  fair  skins  sometimes  show  little  of  the  ham  color  in 
their  syphilitic  eruptions,  and  none  of  the  copper  color  or  subsequent  pig- 
mentation of  scars. 

Hence,  it  becomes  evident  that  there  is  nothing  specific  either  in  color 
or  in  pigment;  yet,  the  peculiarities  of  color  and  of  pigment  are  so  uni- 
form, and  so  well  marked  in  most  cases,  that  they  constitute  a  feature 
which  should  be  always  looked  for  in  eruptions  of  suspected  syphilitic 
origin,  and  to  which  considerable  importance  may  justly  be  attached. 
The  pigmentation  remaining  behind  after  syphilitic  lesions  is  not  perma- 
nent. It  clears  away  promptly  in  light  cases,  more  slowly  in  others.  It 
remains  longest  on  the  lower  extremities.  It  clears  up  from  the  centre 
peripherally,  leaving  any  cicatricial  tissue  which  it  may  have  involved 
more  white  than  the  surrounding  skin.  Occasionally,  especially  around 
a  cicatrix  in  the  lower  extremity,  it  remains  permanently. 

Form  of  the  lesions  and  their  distribution. — The  earlier  erup- 
tions are  generalized  more  or  less  over  the  whole  body,  each  separate  le- 
sion showing  a  tendency  to  assume  the  rounded  form.  Later,  the  lesions 
tend  to  cluster  into  circles,  and  segments  of  circles,  and  to  be  symmetri- 
cal in  their  distribution.  The  latest  lesions  show  little  or  no  tendency  to 
symmetry,  but  preserve  in  a  marked  degree  the  rounded  form.  Gumma- 
tous  ulcers  are  often  composed  of  the  confluence  of  several  gummata,  and 
the  borders  of  the  ulcer  consequently  are  made  up  of  segments  of  large 
circles. 

Absence  of  subjective  symptoms  is  a  marked  feature  of  syphilitic 
eruptions.  In  nearly  every  case,  and  in  nearly  every  class  of  eruption, 
from  the  macule  to  the  most  extensive  ulcer,  there  is  customarily  an  entire 
absence  of  any  itching  or  pain.  This  rule,  like  all  others  in  syphilis,  has 
its  exceptions.  An  acute  outbreak  of  an  early  syphilide  commonly  occa- 
sions a  little  tingling,  but  rarely  any  itching.  Ulcers,  if  connected  with 
bone,  or  upon  the  lower  extremities,  often  pain  considerably,  sometimes 
excessively.  On  the  other  hand,  the  scrofulides,  and  many  gouty  erup- 
tions, with  most  of  the  forms  of  lupus,  are  equally  devoid  of  subjective 
symptoms,  so  that  these  peculiarities  of  syphilitic  eruptions  cannot  be  con- 
sidered to  be  pathognomonic.  Nevertheless,  the  conspicuous  absence  of 
itching  and  pain  is  a  feature  of  great  diagnostic  value  in  connection  with 
the  syphilides. 

The  possibility  of  the  coexistence  of  an  irritable  skin  and  some  pruri- 
tic  condition,  not  syphilitic,  in  connection  with  a  syphilide,  must  be  re- 
membered, together  with  the  fact  that  more  or  less  itching  is  quite  apt  to 
accompany  any  eruption  upon  the  scalp,  of  whatever  nature.  Even  ordi- 
nary acne  of  the  scalp  itches  sometimes. 

The  scabs  and  ulcers  of  syphilitic  lesions  have  some  peculiarities. 
The  scabs  are  apt  to  be  thick,  rough  upon  the  surface,  set  into  the  skin 
at  their  edges,  and  adherent,  unless  undermined  with  pus,  as  in  rupia. 
There  is  generally  also  a  marked  greenish  tint  in  the  scabs,  whether  the 
latter  are  dark  or  light  colored.  This  green  tint  is  often  due  to  the  ad- 
mixture of  a  certain  amount  of  blood  with  the  pus  forming  the  scab.  The 
ulcers  of  syphilis  resemble  chancroidal  ulcers.  Their  borders  are  some- 
times undermined,  but  generally  adherent.  The  floor  is  pale,  uneven, 
more  or  less  pultaceous,  the  discharge  purulent.  The  edges  are  abrupt, 
perpendicular.  The  base  may  be  either  hard  or  soft. 

The  cicatrices  of  syphilitic  lesions  are  quite  uniform  in  their  charac- 


SYPHILIS    OF   THE   SKIN.  145 

ters.  They  are  round,  depressed,  smooth,  thin,  and  not  adherent,  unless 
lying  over  bone.  They  are  dark  at  first,  from  the  pigment  they  contain ; 
and  as  this  clears  off  centrally,  the  scar  grows  white  and  shining,  its  white- 
ness intensified,  and  set  off  by  the  dark  frame  of  pigment  which  lingers 
as  an  areola  about  the  circumference  of  the  cicatrix.  The  cicatrices  of 
ulcers  upon  scrofulous  patients,  and  of  rupial  ulcers  on  all  patients,  are  apt 
to  be  puckered,  drawn,  bridled,  thickened  in  parts,  and  adherent,  like  the 
scars  of  scrofulides. 

THE    SYPHILIDES. 

The  eruptions  found  upon  the  skin  in  secondary  and  intermediary 
(late  secondary)  syphilis  are  seven.  The  last  three  occupy  the  border- 
line, and  may,  any  of  them,  be  found  long  after  the  patient  has  suffered 
from  well-marked  tertiary  gummatous  lesions  of  bone,  or  of  the  other  tis- 
sues. These  three  occur  also  just  as  well  entirely  within  the  secondary 
period,  and  are  best  classed  along  with  secondary  lesions,  since  they  re- 
quire mercury  in  their  treatment  generally  much  more  than  they  do 
iodine.  These  seven  eruptions  are  named  according  to  the  prominent  le- 
sion which  characterizes  them.  They  are  : 

1.  The  erythematous  syphilide  (roseola). 

2.  The  papular  syphilide. 

3.  The  pustular  syphilide. 

4.  The  pigmentary  syphilide. 

5.  The  vesicular  syphilide. 

6.  The  squamous  syphilide. 

7.  The  tubercular  syphilide. 

The  lesions  belonging  to  the  tertiary  period,  all  of  which  are  prone 
to  run  on  to  ulceration,  to  destroy  tissue,  and  leave  scars,  are  three  in 
number  : 

1.  The  pustulo-bulbous  syphilide  (rupia). 

2.  Pustular  syphilide  :  \  ?'  ™th  infiltrated  base  (ecthyma). 

(  0,  in  groups. 

(  a,  as  infiltration  :  -j  J'  non-nloenttive. 

3.  Gumma  :  -j  (2,  ulcerative. 

(  b,  tumor. 

In  connection  with  all  of  these  occur  lesions  on  the  mucous  membranes, 
which  will  be  considered  in  their  proper  place,  and  varied  general  symp- 
toms :  glandular  engorgement,  fever,  alopecia,  etc.,  some  of  which  have 
already  been  considered.  No  one  patient  can  well  have  all  the  syphilides, 
but  he  may  have  a  number  of  them  successively. 


THE   ERYTHEMATOUS   SYPHILIDE. 

This  is  the  most  common  and  the  earliest  of  the  general  syphilides. 
It  may  come  on  within  the  month  after  the  appearance  of  chancre  ;  gener- 
ally it  dates  at  six  weeks  or  two  months,  sometimes  later,  especially  if  de- 
layed by  treatment.  It  first  appears  upon  the  lower  part  of  the  thorax  in 
front,  and  at  the  sides,  over  the  belly,  and  in  the  flanks.  To  see  it  at  the 
10 


146  THE    VENEREAL  DISEASES. 

commencement,  it  is  sometimes  necessary  to  let  the  light  fall  sideways  upon 
the  skin,  freshly  exposed  to  the  cool  air  by  lifting  the  shirt.  A  roseola 
detected  in  this  manner,  of  course,  could  not  be  pronounced  upon  as  being 
certainly  syphilitic  ;  but,  by  examining  a  patient  in  this  way,  often  the 
very  commencement  of  the  eruption  may  be  detected  some  time  before  it 
otherwise  would  have  been  found  out.  A  very  hot  bath  will  frequently 
develop  it  several  days  before  its  natural  date  of  outbreak.  A  sulphur- 
bath  is  particularly  effective  to  this  end.  Patients  do  not  feel  the  erup- 
tion, since  it  does  not  itch,  and  generally  are  unconscious  of  its  existence 
until  the  physician  points  it  out  to  them,  unless  they  have  been  closely 
on  the  lookout  for  it,  in  which  case  they  generally  mistake  the  natural 
marbling  of  the  skin,  due  to  exposure  to  cool  air,  for  roseola,  and  get 
frightened  before  their  time. 

The  eruption  comes  out  as  a  series  of  rounded  macules,  varying  in  di- 
ameter from  one-eighth  to  half  an  inch,  at  first  red,  then  tawny,  then  pig- 
mented.  At  first  the  patches  are  flat,  then  they  often  become  covered 
with  minute  papular  elevations,  and  sometimes  some  of  these  papules  go 
on  to  vesiculation,  occasionally  even  to  mild  pustulation  (although  this  is 
exceptional).  The  patch,  therefore,  is  flat  or  raised,  as  the  case  may  be. 
At  first,  pressure  of  the  finger  causes  the  mottling  entirely  to  disappear; 
later,  a  slight,  livid  staining  remains  behind  after  the  removal  of  pressure; 
finally,  when  the  spot  is  fading,  and  has  become  slightly  coppery  from 
pigment,  pressure  has  no  more  effect  upon  it. 

The  spots  are  never  confluent — healthy  skin  always  exists  between  the 
macules;  but  upon  this  skin  there  maybe  found  a  few  other  lesions  some- 
times, such  as  a  papule  or  a  pustule. 

The  hands  and  face,  where  the  skin  is  tougher,  often  escape  the  erup- 
tion entirely. 

The  lesion  is  due  (Biesiadecki)  to  capillary  dilatation,  escape  of  blood- 
cells  and  their  accumulation  along  the  vessels,  and  a  growth  of  nuclei  in 
the  walls  of  the  latter. 

The  duration  of  roseola  is  from  a  few  days  to  six  or  eight  weeks.  It 
may  relapse.  An  annular  variety  of  large  patches  in  groups,  tending  to 
run  into  the  scaly  form,  is  found  occasionally  at  the  end  of  the  first  year 
of  syphilis.  It  runs  a  slower  course  than  the  roseola,  occurring  soon  after 
chancre.  If  treatment  (mercurial)  has  been  commenced  before  the  ap- 
pearance of  the  eruption,  its  outbreak  is  postponed,  and  it  may  consist 
merely  of  a  few  scattered  macules  upon  the  trunk,  requiring  some  dili- 
gence to  find  them. 

The  diagnosis  of  roseola  due  to  syphilis  is  easy.  The  erythematous 
eruptions  due  to  arsenic,  bromine,  mercury,  belladonna,  quinine,  have  dif- 
ferent situations  and  groupings,  and  are  attended  either  by  internal  fever 
or  local  itching.  Copaibal  ervthema  itches  badly.  Roseola  autumnalis  is 
attended  by  fever,  and  measles  by  its  pathognomonic  prodromata.  The 
glandular,  epitrochlear,  and  post-cervical  engorgement,  the  existence  of 
chancre  and  the  throat  symptoms  (erythema  and  mucous  patches),  to- 
gether with  the  scabs  in  the  hair,  the  night  pains,  and  the  syphilitic  fever, 
if  present,  make  syphilitic  roseola  one  of  the  easiest  to  diagnosticate  of 
all  the  lesions  due  to  syphilis. 

Treatment  is  the  general  treatment  of  secondary  syphilis  by  mercu- 
ry, p.  117. 


SYPHILIS    OF    THE    SKIN. 


147 


THE    PAPULAR    SYPHILIDE. 

This  eruption  may  be  combined  with  a  roseola,  or  follow  the  latter;  or 
it  may  appear  as  the  first  syphilitic  affection  upon  the  skin  after  chancre. 
Its  date  of  appearance  is  therefore  about  the  same  as  that  of  roseola.  The 
papules  vary  in  size,  from  a  minute  acuminated  papule,  such  as  is  seen 
upon  the  macules  of  roseola,  to  a  broad,  flat  papule  as  large  as  a  dime. 
A  common  form  is  the  flat,  lenticular  papule,  of  about  the  size  of  a  large 
split-pea.  These  papules  are  scattered  about,  not  grouped,  occupy  the 
flanks,  the  trunk,  the  extremities,  and 
very  often  the  face.  Fig.  2,  from 
plate  101  of  Fox's  photographic  se- 
ries, shows  the  generalized  distribution 
of  the  eruption. 

The  characteristic  flat  papule,  which 
is  the  most  common  form,  commences 
small,  and  grows  in  all  directions  ex- 
cept in  height.  It  is  hard  and  smooth 
upon  its  surface  at  first,  later  it  is 
sometimes  slightly  depressed  centrally. 
It  is  pink  or  red  at  the  commence- 
ment, but  very  soon  takes  on  the  syph- 
ilitic livid  tint.  It  sheds  its  epithelium 
on  top,  or  the  latter  dries  down  quite 
early  and  cracks  around  the  circum- 
ference of  the  papule.  The  broken, 
rough  edge  of  the  thickened  epidermis 
then  curls  away,  like  a  dirty  lace  collar, 
from  the  base  of  the  flattened  papule, 
giving  the  lesion  a  very  characteristic 
appearance.  The  papules  gradually 
sink  away,  leaving  pigmented  spots, 
but  no  scars.  They  come  out  succes- 
sively, and  may  be  found  in  different 
stages  of  development  upon  different 
parts  of  the  skin. 

On  the  palm  of  the  hand  the  pap- 
ules seem  to  abort,  on  account  of  the 
thickness  of  the  scarfskin.  A  thick- 
ening of  the  scarfskin  seems  to  take 
place,  of  the  size  of  a  papule.  Then 
the  epithelium  gets  yellow  and  dry, 
cracks,  and  drops  out,  leaving  a  clean- 
cut,  punched-out  circle  in.  the  palm,  of 
the  size  of  a  split-pea,  with  a  pink, 
soft,  dry  floor,  covered  with  thin  epithelium,  and  an  undermined,  whit- 
ened border  of  thick,  raised  epithelium,  surrounded  often  by  a  red  areola. 
This  is  the  syphilide  cornee  of  Hardy.  These  spots  often  get  well  with- 
out spreading.  They  differ  from  the  scaly  syphilide  of  the  palm,  which 
usually  occurs  later  in  the  disease.  Sometimes,  however,  these  spots  are 
attended  by  fissuring  and  undermining  of  the  epidermis  laterally,  and 
several  spots  may  coalesce.  This  is  not  the  rule,  but  exceptional. 

There  is  a  large,  flat  form  of  papular  syphilide  sometimes  encountered 


148  THE    VENEREAL    DISEASES. 

upon  the  body,  but  most  apt  to  be  found  upon  the  face  and  scalp.  The 
papules  are  as  large  as  the  finger  or  thumb-nail.  In  the  scalp  they  itch. 
They  are  of  a  pale  pink  color,  desquamate  readily.  Around  their  edge 
the  epidermis  gets  raised  by  a  slight  effusion  of  serum,  while  the  adhe- 
rent cuticle,  bound  down  centrally  in  the  large  lesion,  gives  the  whole  an 
appearance  of  umbilication  which  is  characteristic,  and  not  found,  so  far 
as  I  am  aware,  in  a  lesion  due  to  any  other  cause  than  syphilis. 

A  flat,  livid  papule,  sometimes  excoriated,  sometimes  dry,  is  occasion- 
ally found  indifferently  situated  upon  the  skin. 

When  papules  lie  in  creases  in  the  skin,  so  that  they  are  constantly 
covered  by  other  portions  of  integument  (under  the  breast  in  the  female, 
in  the  groin  in  fat  persons),  and  are  thus  kept  warm  and  subject  to  fric- 
tion, they  are  apt  to  become  very  large  and  flat.  They  sometimes  run 
together  into  patches,  and  become  moist  on  the  surface.  They  may  be- 
come exuberant  and  granulate.  Under  these  circumstances,  the  papule 
becomes  the  mucous  patch  of  the  skin — the  flat  condyloma.  They  are 
common  about  the  anus,  the  scrotum,  the  labia.  The  gray  pellicle  upon 
the  surface  of  these  lesions  recalls  the  typical  mucous  patch  of  the  mucous 
membranes  very  exactly;  and  the  rank,  offensive  odor  of  their  discharges, 
when  retained,  about  the  anus,  genitals,  groins,  under  the  breast,  or  be- 
tween the  toes,  has  something  characteristic  about  it,  which  is  almost  as 
distinctive  as  is  the  smell  of  small-pox.  The  true  mucous  patch  of  mu- 
cous membranes  is  indeed  a  papule,  and  the  papule  on  the  skin  is  custom- 
arily associated  with  the  mucous  patch  upon  the  mucous  membranes. 

Just  as  mucous  patches  upon  mucous  membranes  may  ulcerate,  the 
ulcer  eat  into  the  substance  of  the  tissue  bearing  it,  and  a  scar  result,  so 
may  it  happen  to  a  moist  condyloma  of  the  skin;  and  the  ulcer,  once 
started,  may  spread  far  beyond  the  limits  of  the  original  lesion.  This, 
however,  is  not  a  common  occurrence.  It  is  more  apt  to  happen  to  mu- 
cous tubercles  about  the  throat,  the  anus,  or  the  genitals,  than  elsewhere. 

Dry  papules  of  the  skin  sometimes  run  together  and  scab  over,  their 
surface  being  somewhat  warty  and  covered  with  crusts.  This  condition  is 
best  seen  in  the  furrows  bordering  the  upper  lip,  and  in  the  moustache 
about  the  nose.  Occasionally  large  patches  of  papules  run  together  and 
vegetate,  resulting  in  a  raised  raw  surface,  which  finally  scabs  over  and 
eventually  scales. 

The  secretions  from  moist  papules  on  the  skin  are  contagious,  and,  on 
account  of  their  widespread  distribution,  these  papules  are  more  danger- 
ous than  even  the  primary  lesion  of  syphilis.  The  discharge  is  also  auto- 
inoculable,  especially  if  the  surface  of  the  papule  be  irritated  and  made 
to  discharge  pus.  Under  such  circumstances  auto-inoculation  may  pro- 
duce an  ulcer  resembling  chancroid.  Spontaneous  auto-inoculation  of  a 
moist  syphilitic  papule  produces  another  moist  syphilitic  papule.  This  is 
frequently  seen  clinically. 

The  papules  in  the  syphilitic  negro  are  generally  hyper-pigmented  on 
their  summits  or  around  the  base.  Taylor1  has  reported  (Fig.  3,  after 
104,  Fox)  two  cases  in  the  negro,  showing  the  white  color  produced  in 
some  cases  by  the  scales  upon  the  papules  during  desquamation. 

The  duration  of  the  papular  syphilide  is  very  variable.  It  may 
come  out  as  the  first  eruption,  either  alone  or  mixed  with  the  roseola, 
and  continue  for  a  period  varying  from  a  few  weeks  to  many  months. 
When  apparently  getting  well,  it  sometimes  suddenly  relapses  without 

'Am.  Jour,  of  Syph.  and  Derm.,  Vol.  IV.,  No.  IL,  p.  107. 


SYPHILIS    OF    THE    SKIN. 


149 


apparent  cause.     The  lesions  on  the  palms  and  soles,  especially  if  they 
run  together  into  patches,  are  particularly  obstinate. 

Treatment  greatly  affects  the  duration  of  all  forms  of  papular  syphi- 
lide.  Local  treatment  is  often  especially  valuable  (p.  128),  particularly 
for  papular  lesions  upon  the  cheeks  or  forehead  (corona  veneris) — situa- 
tions very  apt  to  be  occupied  by  papules,  which  seem  to  run  an  especially 
slow  course  in  these  localities.  Local  treatment, 
properly  adapted  to  the  lesion,  certainly  modifies 
all  forms  of  syphilitic  eruption. 

Syphilitic  papules,  unless  they  ulcerate,  leave 
no  scars.  They  frequently  leave  pigmented  areas 
behind,  marking  the  site  of  the  lesion.  The 
pigment  slowly  disappears  with  time,  sometimes 
centrifugally  leaving  a  pigmented  margin,  which 
may  persist  long  after  the  centre  has  become 
whiter  than  the  surrounding  skin.  The  color  is 
most  apt  to  be  marked  in  dark-skinned  persons 
upon  the  naturally  pigmented  skin  about  the 
anus  and  genitals. 

The  | diagnosis  of  papular  syphilide  is  very 
easy  in  typical  cases,  especially  if  the  eruption 
is  copious,  and  other  concomitant  signs  of  early 
syphilis  are  present. 

Difficulties  may  arise,  however,  when  there 
are  only  a  few  papules.  A  few  acuminated  pap- 
ules can — with  difficulty,  if  at  all — be  distinguish- 
ed from  indolent  papules  of  acne,  found  after 
middle  life  in  gouty  people  of  dark  complexion. 
The  pigmented  area  surrounding  the  site  of  a 
papule  which  has  run  its  course  is  suggestive,  but 
not  pathognomonic,  of  syphilis.  In  some  cases 
the  result  of  treatment  alone  will  justify  a  diag- 
nosis. A  mixed  treatment  cures  the  late  scattered 
syphilitic  papule  in  every  case  where  the  stomach 
is  in  a  fair  state,  while  the  acne  upon  a  rheuma- 
tic, gouty  patient  is  not  at  all  favorably  influenced 
by  such  a  course. 

Flat  papules,  when  occurring  in  an  isolated 
way,  late  in  syphilis,  are  also  indistinguishable 
from  similar  isolated  accidental  lesions,  due  to  in- 
different causes,  upon  rheumatic  subjects.  Treat- 
ment here  again  becomes  the  most  valuable  aid  to 
diagnosis,  or  better  still,  observation,  since  iso- 
lated syphilitic  papules  do  not  reproduce  themselves  indefinitely,  while  upon 
certain  gouty  subjects  they  recur  from  time  to  time  with  reasonable  regu- 
larity. 

Lichen  plamis,  of  all  eruptions,  is  with  the  most  difficulty  differen- 
tiated from  a  papular  syphilide.  The  color  is  identical,  and  many  other 
features  are  the  same.  The  most  positive  distinguishing  marks  are  the 
umbilication  of  many  of  the  solid  papules  of  lichen  planus,  their  wide  dif- 
ference in  size,  their  very  marked  tendency  to  run  into  patches,  and  their 
tendency  to  arrange  themselves  in  lines  with  healthy  skin  between  the 
different  lesions  rather  than  in  circles,  as  is  the  case  in  syphilitic  disease. 
Moreover,  with  lichen  planus  there  are  no  concomitant  symptoms  of  syphi- 


150 


THE   VENEREAL   DISEASES. 


lis  found  in  the  lymphatic  glands  or  on  the  mucous  membranes,  which 
could  hardly  be  the  case  in  an  eruption  of  syphilitic  papules  of  like  inten- 
sity. The  palms  and  soles  are  much  more  apt 
to  be  spared  in  lichen  planus  than  in  a  syph- 
ilitic papular  eruption. 

The  flat -raised  papule  (condyloma  lata) 
generally  accompanies  other  syphilitic  lesions, 
and  is  relatively  easy  of  diagnosis.  When 
seen  alone  about  the  anus,  as  in  Fig.  4  (after 
29,  Fox),  a  doubt  sometimes  arises  as  to 
whether  the  lesions  may  not  be  the  ordinary 
vegetations,  the  so-called  venereal  warts,  which 
are  apt  to  be  found  in  connection  with  gonor- 
rhreal,  leucorrhceal,  and  other  discharges — in- 
deed, complicating  all  manner  of  unclean- 
ness. 

The  venereal  wart  is  more  uneven  on  the 
surface  than  the  condyloma  lata,  more  split 
up  and  segmented  into  pointed  papillae,  like 
the  ordinary  "seed  wart."  A  large  cluster 
of  them  may  grow  off  from  the  skin  in  a  pe- 
dunculated  manner.  Their  color  is  apt  to  be 
more  brilliant  than  that  of  the  syphilitic  pap- 
ule, and  their  situation  is  less  frequently  the 
anus  or  scrotum.  They  lie  most  often  within 
the  ostium  vaginae  in  the  female;  under  the  foreskin  in  the  male.  Men- 
tion will  be  made  again  of  these  warts  in  connection  with  the  study  of 
gonorrhoea.  They  may  occur  as  a  complication  of  true  mucous  patches 
under  the  foreskin,  in  the  vagina,  at  the  anus. 

Treatment  is  that  of  secondary  syphilis  by  mercury. 


Fio.  4. 


THE    PUSTULAR    SYPIIILIDE. 

The  pustules  of  early  syphilis  are  found  in  two  varieties:  (1)  small, 
scattered  or  grouped,  arising  within  a  follicle,  or  occurring  independently 
upon  an  intervening  portion  of  skin;  (2)  upon  an  inflamed  base,  but  still 
superficial,  not  gummatous  (superficial  ecthyma). 

The  small  pustule  has  no  very  distinctive  marking.  It  is  apt  to  be 
generalized  over  the  whole  body  in  early  syphilis,  and  usually  indicates 
such  a  pus-forming  quality  of  constitution  in  the  patient,  that  the  course 
of  his  subsequent  syphilis  may  with  reasonable  confidence  be  expected  to 
be  bad. 

The  pustular  syphilide  may  come  on  as  the  earliest  eruption  at  six 
weeks,  but  it  does  not  usually  appear  before  as  many  months.  The  scat- 
tered pustules  found  among  a  number  of  vesicles,  papules,  and  erythema- 
tous  spots  in  the  polymorphism  of  the  first  eruption,  do  not  constitute  a  pus- 
tular syphilide.  In  the  latter  the  type  lesion  is  the  pustule,  grouped  or 
discrete.  The  lesions  are  found  scattered  over  the  whole  body,  in  the 
scalp,  upon  the  face,  upon  the  fingers  and  palms,  over  the  whole  trunk  and 
extremities.  Very  often  the  sebaceous  follicle  is  involved,  and  then  a  hair 
is  seen  to  project  from  the  summit  of  each  pustule.  They  vary  greatly 
in  size,  take  severally  from  one  to  three  weeks  to  reach  perfection,  and 
then  they  usually  break  and  scab,  or  dry  down  and  heal  up  under  the  lit- 


SYPHILIS    OF   THE    SKIN.  151 

tie  crust.  When  they  run  together  into  superficial  patches,  they  behave 
in  much  the  same  way. 

When  the  dried-up  scabs  fall  away  the  livid  thickening  of  the  skin 
remains  for  a  considerable  period  marking  the  sites  of  the  lesions. 
These  livid  papules  (for  such  they  are)  may  be  marked  by  a  central  de- 
pression— the  hole  left  by  the  suppurated  follicle — if  the  pustule  has  been 
pierced  by  a  hair;  or  they  may  remain  ulcerated  on  top  for  a  time,  finally 
yielding  a  thin,  white,  round  scar.  A  ring  of  pigment  around  each  sepa- 
rate healing  lesion  in  pustular  syphilis  is  rather  the  rule  than  the  ex- 
ception; but  the  pigment  finally  disappears,  and  the  scars  are  often  so 
faint  that  it  becomes  hard  to  detect  even  traces  of  them  in  later  years. 
Groups  of  superficial  pustules  are  much  more  rare  than  numbers  of  dis- 
crete pustules. 

The  pustular  syphilide  is  slow.  Crops  of  pustules  come  out  at  differ- 
ent times,  relapses  are  not  uncommon;  and,  unless  treatment  aided  by 
tonics  shortens  the  duration  of  the  affection,  it  is  apt  to  drag  itself  along 
during  several  months. 

The  diagnosis  of  superficial  pustular  syphilide  is  generally  easy  from 
the  concomitant  symptoms  and  history.  Iritis  is  apt  to  complicate  it. 
The  bronzed  areola  of  the  subsiding  lesion  is  a  great  help  to  diagnosis. 
A  generalized,  pustular,  superficial,  discrete  eruption  is  very  rarely  due 
to  any  other  cause  than  syphilis,  and  the  appearance  of  such  an  eruption 
should  immediately  suggest  an  inquiry  into  the  patient's  previous  history. 

The  superficial  ecthymatous  syphilide  (Fig.  5)  is  a  little  deeper, 
a  little  more  intense,  being  more  deeply  seated  than  the  simple  early 
pustular  syphilide.  It  indicates  that  the  patient  has  a  bad  type  of 
syphilis,  especially  if  it  comes  on  early.  It  generally  appears  as  late  as 
during  the  second  year — late  enough  to  be  called  tertiary;  but  in  bad 
cases  it  often  comes  on  early,  within  a  few  weeks  of  chancre,  and  it 
leaves  a  faint  scar,  not  indicating  any  considerable  destruction  of  tissue. 
Occasionally,  on  the  other  hand,  it  accompanies  early  malignant  lesions  in 
very  bad  syphilis,  and  destroys  considerable  tissue,  which  of  course  neces- 
sitates a  deep  scar. 

This  syphilide  starts  as  an  infiltration  of  a  limited  area  of  skin  capped 
by  a  pustule,  or  of  a  patch  of  skin  upon  which  several  pustules  appear, 
at  first  discrete,  later  confluent.  These  pustules  are  generally  large  and 
flattened;  they  may  even  be  umbilicated,  resembling  variola.  The  pus- 
tules develop  rather  slowly,  with  little  or  no  pain,  and  finally  scab,  an 
ulcer  existing  under  the  scab  for  some  time  -after  the  latter  has  formed. 
The  pigmented  areola  comes  on  during  the  latter  part  of  the  develop- 
ment of  the  pustules.  The  scar  remains  long  purple,  often  raised  and 
thick,  generally  pigmented,  and  sometimes  pitted,  the  pits  representing 
different  follicles  which  have  suppurated.  Finally  the  scars  become  per- 
fectly white,  more  slowly  upon  the  lower  than  upon  the  upper  extremities. 

The  diagnosis  of  this  form  of  syphilis  is  not  difficult  except  in  occa- 
sional cases  where,  as  sometimes  occurs,  fever  runs  high  with  the  first 
outbreak  of  the  pustules,  and  where  umbilication  is  marked.  A  mistake 
has  been  often  made  in  such  cases,  and  the  patient  has  been  sent  to  a 
small-pox  hospital.  Several  instances  of  this  error  have  come  under  my 
notice.  The  mistake  may  be  avoided  by  noticing  the  more  sluggish  de- 
velopment of  the  syphilitic  pustules  in  crops,  the  absence  of  intense  pain 
in  the  back,  the  history  of  the  case,  and  the  concomitance  of  other  (mouth 
and  glandular)  evidences  of  syphilis. 

Cachectic  ecthyma  upon  a  young  person  with  a  dark  skin  often 


152 


THE   VENEREAL    DISEASES. 


cannot  possibly  be  differentiated  from  superficial  syphilitic  ecthyma  by  a 
study  of  the  lesion  alone.  The  areola  of  pigment  may  be  perfect  upon 
the  cachectic,  probably  lousy,  pauper  encountered  in  hospital  practice, 
and  suffering  from  simple  ecthyma.  A  close  study  of  the  history  and 
accompanying  symptoms  is  the  only  guide  to  a  safe  diagnosis.  Anti- 


Fio.  5.    After  7,  Fox's  photographs. 


syphilitic  treatment,  quite  effective  in  syphilitic  superficial  ecthyma,  is 
powerless  to  oppose  a  continuance  of  the  cachectic  form. 

The  superficial  ecthyma  of  early  syphilis  differs  from  the  deep  ecthyma 
of  late  syphilis,  in  that  the  latter  is  a  gummy  infiltration  of  the  true  skin, 
has  a  livid,  hard  base,  and  always  leaves  a  depressed,  round,  white,  thin, 
smooth,  unpitted  scar. 

Treatment  is  that  of  secondary  syphilis  by  mercury  (p.  117 ). 


THE   PIGMENTARY   SYPHILIDE. 


This  eruption,  the  very  existence  of  which   is  questioned  by  some 
authors,  while  its  syphilitic  character  is  doubted  by  many  who  acknowl- 


SYPHILIS    OF   THE   SKIN.  153 

edge  its  existence,  was  first  accurately  described  by  Hardy,  later  by  Four- 
nier.  Quite  recently  Atkinson, '  of  Baltimore,  and  G.  H.  Fox,4  of  New- 
York,  have  contributed  valuable  essays  to  the  literature  of  the  subject. 

This  syphilide  is  simply  a  coloration  of  the  integument,  varying  from 
a  light  dirty  brown  color  to  almost  a  black,  a  mottling  formed  of  patches, 
light  and  dark.  The  light  areas  of  skin  are  sometimes  of  a  natural  hue, 
sometimes  whiter  than  the  original  integument,  meriting  for  the  affection 
the  title  of  vitiligo,  according  to  Fox,  who  has  one  dark-skinned  Italian 
patient  among  his  photographs,  illustrating  the  blanching  of  the  skin 
upon  the  sites  of  the  lesions  without  hyper-pigmentation  around. 

The  conclusions  arrived  at  by  Fox,  as  to  the  method  of  formation  of 
the  pigmentary  syphilide,  are  very  interesting.     They  are  based  upon  the 
close  study  of  several  cases,  and,  although 
not  proved  yet,  they  are  so  plausible  that  /     \ 

their  truth  seems  more  than  probable.  (  J  I 

The  accompanying  diagrammatic  sketch  ^«— ^ 

has  been  furnished  me  by  Dr.  Fox.  If  these 
views  stand  the  test  of  observation  by  the 
profession  at  large,  another  of  the  minor 
mysteries  of  syphilis  will  have  been  solved. 

In  Fig.  6,  the  round  spot  1  represents 
the  red  syphilitic  macule  or  papule;  2  is  the 
pigmentation  which  follows  in  many  cases;  3  /*"* "\ 

is  the  dark  centre,  the   "  bull's  eye,"  as  Dr.  *         3 

Fox  calls  it,  which  he  has  noticed  to  remain 
in  the  centre  of  the  white  area  as  the  pig- 
ment was  being  absorbed  peripherally;  4 
shows  the  "  bull's  eye "  also  absorbed,  as 
well  as  all  the  pigment  originally  occupy- 
ing the  site  of  the  lesion,  while  there  re- 
mains generalized  peripheral  hyper-pigmen- 
tation in  the  intermacular  spaces. 

The  dark  patches  are  quite  irregular  and 
vary  much  in  size,  their  festooned  borders 
running  into  each  other  and  making  the  ir- 
regular mottling  already  referred  to.  The 
eruption  is  generally  found  upon  the  sides 

of  the  neck,  in  front,  and  on  the  upper  part  of  the  chest;  exceptionally 
elsewhere,  as  upon  the  trunk,  the  hands.  It  is  generally  ignored  by  the 
patient,  and  often  only  discovered  through  accident  by  the  physician,  or 
after  careful  search.  Lymphatic,  fair-skinned  women,  according  to  Hardy 
and  Fournier,  are  most  apt  to  have  this  eruption ;  but  men  also  have  it, 
and  sometimes  very  dark-skinned  patients  (Fox). 

No  one  has  ever  watched  it  develop;  but  Fox  has  marked  certain 
papular  lesions  on  the  neck,  and  found  the  white  mottlings,  afterward,  to 
correspond  to  the  sites  marked  out  by  the  forerunning  eruption.  The 
lesion  has  been  considered,  also,  to  be  the  lesion  left  behind  by  a  roseola, 
and  at  best  it  is  an  obscure  affection  of  but  little  moment.  As  corrobora- 
tive of  past  syphilis,  it  may  be  of  some  value.  It  comes  on  anywhere  in 
the  second  half  of  the  first  year  after  chancre,  and  may  last  many  months, 
but  it  always  finally  disapears.  It  is  totally  devoid  of  any  subjective 

1  Trans.  Am.  Dermatological  Society,  1878. 
*  Am.  Journ.  Med.  Sci.,  April,  1878,  p.  356. 


154  THE    VENEREAL   DISEASES. 

symptoms,  and  absolutely  uninfluenced  by  treatment.  It  cannot  possibly 
be  mistaken  for  anything  except  dirt,  pityriasis  versicolor,  freckles,  or 
leucoderma.  The  first  of  these  washes  off;  the  second  itches  faintly,  is  a 
little  branny,  and  furnishes  spores  for  microscopic  diagnosis;  the  third  are 
more  yellow,  and  never  confined  to  the  limited  region  of  the  sides  of  the 
neck  and  upper  part  of  the  chest.  Leucoderma  of  the  common  sort  has 
a  different  distribution. 


THE   VESICULAR   SYPHILIDE. 

This  eruption  is  rare.  Its  date  of  appearance  is  late  in  the  secondary 
period,  generally  during  the  second  year  after  chancre. 

The  vesicles  may  be  of  varied  size,  but  generally  are  small,  acuminated, 
scattered  about  the  trunk  and  extremities  (the  face  being  spared),  or  clus- 
tered into  groups  in  circles,  or  segments  of  circles,  upon  a  livid  base  of 
characteristic  syphilitic  color.  Each  of  the  lesions  may  be  surrounded  by 
an  areola,  at  first  livid,  then  coppery,  and  the  vesicles  may  dry  up  and  scale, 
or  become  purulent  and  scab  over. 

There  is  a  form  of  vesicular  syphilide  coming  on  earlier  (within  six 
months  after  chancre),  the  vesicles  being  large,  umbilicated,  upon  a  red- 
dened base,  with  an  areola  at  first  livid,  then  coppery.  The  vesicles  quickly 
become  purulent. 

All  the  vesicular  syphilides  are  slow  in  evolution  and  apt  to  be  pro- 
longed by  successive  outcrops  cf  new  vesicles  and  clusters  of  vesicles  con- 
tinuing to  appear  as  the  first  dry  up.  The  livid  spots  left  by  the  vesicles 
gradually  whiten  and  leave  either  no  scar  or  pitted  cicatrices,  each  pit  rep- 
resenting the  original  site  of  a  vesicle. 

The  diagnosis  is  easy.  The  umbilicated  vesicle  may  suggest  varicella, 
but  there  is  no  itching  except  in  the  scalp,  and  other  syphilitic  lesions  are 
apt  to  accompany  this  umbilicated  form  of  the  eruption,  which  comes  on 
early  in  the  disease  if  at  all.  The  generalized  vesicular  syphilide  does  not 
become  confluent  and  yield  an  oozing  surface  as  does  eczema.  The  color, 
the  areola,  the  grouping,  the  absence  of  itching,  distinguish  it  easily  from 
other  vesicular  eruptions.  Treatment  is  that  of  secondary  syphilis  by 
mercury  (p.  117). 


THE   SQUAMOUS   SYPHILIDE. 

The  squamous  syphilide,  except  upon  the  palms  and  soles,  is  usually  a 
papulo-squamous  or  a  tuberculo-squamous  eruption  in  infiltrated  rounded 
patches  of  livid  form,  or  with  a  circinate  distribution  recalling  ringworm 
(Fig.  7,  after  226,  Fox).  The  scaling  which  occurs  as  the  last  stage,  in  a 
variety  of  eruptions  due  to  syphilis,  cannot  be  called  a  squamous  syphi- 
lide, and  the  pityriasis  accompanying  alopecia  due  to  syphilis  is  manifestly 
unworthy  to  be  called  a  squamous  syphilide. 

The  papulo-squamous  syphilide  occurs  toward  the  end  of  the  first  year 
of  syphilis,  or  at  any  period  later.  It  may  come  on  long  after  the  tertiary 
stage  has  set  in,  after  gummata  have  appeared,  after  bone  disease  has  been 
inaugurated  and  cured.  Long  after  the  patient  thinks  himself  well,  sev- 
eral years  perhaps  after  the  appearance  of  any  symptom  due  to  syphilis, 
an  elevated  patch  of  squamous  syphilide  may  appear  upon  the  face  and  be 
unjustly  called  a  lupus  by  the  physician, — or  a  circinate  scaly  eruption 


SYPHILIS    OF   THE    SKIN". 


155 


comes  out  upon  the  scrotum,  and  here  the  patient  looks  upon  it  as  a  ring-- 
worm. 

Solid  patches  of  squamous  syphilide  may  occur  upon  the  face  or  any 
part  of  the  body.  The  skin  is  thickened,  more  or  less  livid,  often  not  dis- 
tinctly papulated,  but  infiltrated.  The  size  and  shape  of  the  patches  vary 
greatly,  from  small  dots  to  broad,  rounded  sweeps  of  eruption  as  large 
as  the  hand.  The  livid  surface  is  covered  with  fine  white  scales,  which 
are  not  tightly  adherent.  These  scales  shed  off  and  are  replaced  by  new 
crops,  until  finally  the  infiltration  disappears  and  the  patch  gets  well,  leav- 
ing no  scar.  If  the  patch  has  been  positively  tuberculated  as  well  as 
scaly,  round  scars,  not  much,  if  at  all,  pig- 
mented,  are  apt  to  be  scattered  over  the  livid 
scaly  area  covered  by  the  eruption,  and  these 
scars  remain  permanent  after  the  affection 
gets  well. 

The  circinate  form  may  come  on  early 
or  very  late  in  syphilis,  attacking  any  part  of 
the  body,  but  most  common  upon  the  scro- 
tum, or  about  the  genitals,  in  either  sex.  The 
circle,  or  segment  of  a  circle,  starts  of  a  given 
size,  and  does  not  increase  like  ringworm. 
A  number  of  segments  of  circles  often  run 
into  each  other,  making  a  festooned,  gyrate 
figure.  The  border  of  the  circle  forming  the 
eruption  varies  in  breadth  up  to  about  a 
quarter  of  an  inch;  generally  it  is  but  little 
wider  than  an  eighth  of  an  inch  on  the  scro- 
tum. The  skin  enclosed  by  the  segments  of 
circles  remains  sound.  The  border  of  the 
circle  is  generally  distinctly  papulated,  some 
of  the  papules  being  dry,  some  moist,  some 
scaly,  some  scabbed.  About  the  genitals  patients  sometimes  assert  that 
the  eruption  itches. 

When  this  eruption  occurs  early  in  syphilis,  it  is  apt  to  coincide  with 
other  manifestations  of  the  disease;  later,  it  may  be  solitary.  The  later 
it  appears,  the  slower  it  is  in  evolution.  It  does  not  leave  a  scar. 

Diagnosis  in  squamous  syphilis  is  often  difficult.  Coincident  symptoms 
of  syphilis,  and  the  history,  together  with  the  common  situation  along 
the  roots  of  the  hair  on  the  forehead,  about  the  genitals,  etc.,  help  to  make 
a  diagnosis  which  the  effect  of  treatment  will  promptly  justify  if  it  has 
been  accurate.  In  color,  on  the  other  hand,  and  general  arrangement, 
patches  of  squamous  syphilide  are  sometimes  quite  indistinguishable  from 
some  forms  of  psoriasis,  and  a  localized  patch  on  the  face  is  sometimes 
nearly  enough  like  erythematous  lupus  to  deceive  a  practitioner  not  ex- 
pert in  the  differential  diagnosis  of  skin  diseases.  The  circinate,  scaly 
syphilide  cannot  long  be  mistaken  for  ringworm,  since  in  syphilis  the  cir- 
cle does  not  grow  by  centrifugal  enlargement. 

The  palmar  and  plantar  squamous  syphilides  are  lesions  of  the 
first  importance  in  connection  with  syphilis.  There  are  several  varieties 
of  this  eruption.  One  of  them  has  already  been  described  (p.  147),  namely, 
the  round,  livid,  dry  spots  on  the  palm,  looking  as  if  a  piece  of  the  epithe- 
lial layer  had  been  cut  out  with  a  punch  (Fig.  8,  after  73,  Fox),  and  the 
borders  of  the  scarfskin  afterward  slightly  undermined.  Besides  these 
spots,  which  are  best  observed  in  connection  with  a  generalized  papular 


FIG.  7. 


156 


THE   VENEREAL    DISEASES. 


syphilide,  other  rounded  and  oblong  scaly  patches  of  the  palm  and  sole 
are  encountered  in  syphilis  at  almost  every  stage  of  the  disease. 

These  are,  with  few  exceptions,  round  and  oval.  The  different  lesions 
commence  as  livid,  red  areas,  or  as  round,  epidermal  patches  of  a  yellow 
color,  according  as  congestion  of  the  surface  vessels  or  epithelial  hyper- 


FIG.  8. 


trophy  is  the  more  pronounced  pathological  process.  As  the  lesion  pro- 
gresses it  spreads  centrifugally,  the  epidermis  fissures  and  scales  off,  and 
the  different  lesions  run  into  each  other  (Fig.  9,  after  77,  Fox),  making  a 
large  patch  with  irregular,  rounded  border.  The  centrifugal  spread  of 
the  patches  leaves  a  livid,  pink  centre,  free  from  any  special  lesion  other 


Fro.  9. 


than  hyperaemia.  Upon  such  central  reddened  spots,  other  rounded  lesions, 
like  those  in  which  the  affection  originated,  spring  up,  and  in  their  turn 
spread  centrifugally.  In  the  natural  furrows  of  the  palm  or  sole,  and  at 
their  border,  deep  fissures  are  apt  to  form  in  the  edges  of  the  eruption, 
due  primarily  to  motion,  and  extending  down  into  the  bleeding  true 


SYPHILIS    OF    THE    SKIN.  157 

skin.  These  cracks  are  aggravated  by  motion,  and  are  the  seat  of  con- 
siderable pain  at  times. 

Friction  upon  the  palm,  as  in  rowing,  using  tools,  etc.,  is  an  active, 
exciting  cause  of  squamous  syphilides  in  this  region;  much  walking  and 
ill-fitting  shoes  act  in  the  same  way  upon  the  sole.  In  the  latter  region 
about  the  heel,  in  the  very  thick  epidermis  of  that  locality,  the  squamous 
syphilide  sometimes  occurs  as  a  dirty,  yellow,  fissured  condition  of  the 
epidermis,  cropping  over  upon  the  thin  skin  under  the  ankle  as  a  livid, 
scaly  eruption  bordered  by  segments  of  circles.  In  this  region  the  scaly 
syphilide  is  often  attended  by  pain,  due  to  fissuring  of  the  true  skin,  and 
is  very  slow  in  its  evolution.  Elevated  livid  tubercles,  more  or  less  scaly, 
also  occur  in  patches  upon  the  palm. 

Symmetry  is  not  the  rule  in  either  palmar  or  plantar  syphilis. 

Diagnosis  of  squamous  syphilide  of  the  palm  and  sole  is  difficult  in 
some  cases.  Some  forms  of  lichen  urticatus,  of  eczema,  and  of  psoriasis 
resemble  it  very  closely.  In  the  first  and  last  of  these  affections,  how- 
ever, the  plantar  or  palmar  lesion  is  never  found  alone.  The  character  of 
general  eruption  upon  the  rest  of  the  body,  therefore,  clears  up  all  doubt 
concerning  the  lesion  in  question.  An  eczematous  patch,  however,  may 
be  found  exclusively  confined  to  the  palm.  It  is  apt  to  itch,  it  is  thinner 
at  the  edge,  shades  off  into  the  surrounding  integument  more  than  the 
syphilide  does.  It  is  not  so  livid  in  color,  and  has  no  purple  border,  as  is 
sometimes  the  case  in  the  syphilide.  Eczema  is  more  irregular,  less 
rounded  in  outline,  much  more  chronic  in  duration,  as  a  rule,  and  apt  to 
extend  out  over  the  palm  upon  the  softer  skin  around. 

Local  treatment  is  of  great  value,  as  well  as  general  treatment,  in 
this  affection.  The  tuberculo-squamous  patches  generally  require  mixed 
treatment  (pp.  117,  128,  137). 


THE   TTJBEECULAE  SYPHILIDE. 

This  syphilide  occurs  in  two  forms — generalized,  or  in  groups.  The 
generalized  form  is  quite  unusual,  that  in  groups  very  common.  The 
former  rarely  occurs  before  the  second  half  of  the  first  year,  from  chancre; 
the  latter  quite  exceptionally  before  the  second  year.  Isolated  patches 
of  tubercle  may  come  on  at  any  date,  many  years  after  all  traces  of  the 
disease  have  disappeared. 

The  general  tubercular  syphilide  is  not  the  papular  syphilide  in 
which  the  papules  are  large.  The  tubercle  is  really  a  gummatous  product. 
It  develops  deeply  down  in  the  tissue  or  the  true  skin  beneath  the  papillary 
layer.  It  is  not  a  gummy  tumor  of  the  subcutaneous  tissue.  When  it 
occurs  as  a  generalized  eruption,  it  does  so  as  an  eruption  of  patches 
and  groups  of  clustered  lesions  in  circles  and  segments  of  circles.  Some 
of  the  patches  are  the  result  of  a  confluence  of  many  tubercles,  and  then 
the  patch  is  a  solid  livid  elevation  of  the  skin,  uneven  on  the  top,  and  cov- 
ered with  scales.  Each  separate  lesion,  if  it  stands  alone  (Fig.  10,  after 
103,  Fox),  is  livid  in  hue,  capped  with  a  scale  or  a  small  pustule,  and 
often  surrounded  by  a  livid  areola,  afterward  becoming  coppery.  The 
different  tubercles  vary  in  size  from  a  grain  of  rice  to  a  good-sized  pea, 
and  they  usually  leave  a  cicatrix  when  they  disappear,  whether  their  sur- 
face has  been  ulcerated  or  not.  The  scar  is  at  first  livid,  then  often  pig- 
mented,  then  white,  round,  thin,  smooth,  depressed,  not  at  all  retractile. 


158 


THE   VENEREAL    DISEASES. 


The  diagnosis  is  easy.  It  is  hard  to  imagine  an  eruption  with  which 
the  tubercular  syphilide  could  be  confounded. 

The  tuberculo-squamous  or  tuberculo-ulcerated  syphilide  in 
groups  is  a  late  lesion.  It  is,  indeed,  positively  tertiary,  but  often  oc- 
curs upon  the  border-line.  The  face  is  a  favorite  seat  of  the  eruption,  but 
it  may  occupy  any  part  of  the  body,  as  shown  in  Fig.  11,  after  108,  Fox. 
Livid  patches  of  thickened  skin  constitute  the  eruption. 

Scales  upon  these  patches  are  quite  obvious,  but  the  tubercles  may  be 


Fio.  10.    Generalized  tubercular  syphilis. 

scarcely  so,  perhaps  not  visible  at  all.  Sometimes  the  only  reason  one 
has  to  call  the  affection  tuberculo-squamous,  is  the  existence  of  round, 
white,  depressed  scars  upon  the  surface  in  among  the  scales,  of  the  size 
of  a  pea,  marking  the  site  of  tubercular  infiltrations  of  the  true  skin,  with 
gummatous  material,  the  interstitial  absorption  of  which  has  produced  the 
white  scars.  Generally  the  tubercles  are  quite  plainly  visible  upon  the 
surface.  Sometimes  they  stand  apart,  sometimes  they  run  together  and 
enclose  areas  of  healthy  skin  within  raised  circular  borders. 


SYPHILIS    OF   THE    SKIN". 


159 


The  evolution  of  the  patch  is  by  the  circumferential  growth  of  new 
tubercles.  Those  first  formed  disappear,  leaving  scars  without  previously 
ulcerating,  and  upon  the  old  spots  where 
former  tubercles  have  flourished  and 
gone  away  new  ones  may  crop  out  later 
and  go  slowly  through  their  changes, 
leaving  scars  behind.  Ringworm  may 
be  simulated  by  circinate  patches  of 
tuberculo-squamous  disease. 

This  syphilide  is  maintained  by  the 
successive  outcrop  of  new  tubercles, 
and  a  single  patch  may  thus  be  pro- 
longed for  years.  Sometimes  the  gum- 
matous  infiltration  which  forms  the  tu- 
bercle goes  on  so  rapidly  that  the  in- 
tegrity of  the  integument  is  compro- 
mised, ulceration  takes  place,  and  a 
serpiginous  ulcer  results,  as  after  the 
pustular  syphilide  in  groups. 

The  diagnosis  of  tubercular  syph- 
ilide in  groups  is  very  easy  if  atten- 
tion be  paid  to  the  central  cicatrices 
in  the  patch.     These  are  round,  white, 
smooth,  and  not  puckered.     In  tuber- 
cular non-ulcerative  lupus  this  quality 
of  Scar  is   not  observed,  the    cicatrix  . 
being  puckered  and  linear.     This  fea- 
ture alone  is  all  that  is  required  to  make  a  distinction.     The  lividity  of 
color  is  much  more  marked  in  syphilis  than  in  lupus. 

Treatment  is  mixed,  both  iodide  of  potassium  and  mercury  being  re- 
quired (p.  137).     Local  treatment  is  serviceable  (p.  128). 


PIG.  11. 


TEETIAEY   SYPHILIDES. 

The  final  three  sets  of  eruptions  to  be  considered — rupia,  ulcerative 
syphilis,  and  gumma — are  strictly  tertiary;  they  all  call  for  mixed  treat- 
ment, and  generally  for  the  iodide  of  potassium  in  excess,  if  it  is  desired 
to  subdue  them  promptly.  They  all  occur  habitually  in  the  second  year 
of  the  disease  and  later,  and  they  uniformly  and  inevitably  destroy  the 
structure  of  the  true  skin  and  leave  scars.  Treatment  postpones  their 
outbreak,  or  may  prevent  them  from  appearing  at  all. 

Eruptions  of  this  kind  may  be  ushered  in  while  the  patient  is  enjoying 
apparently  the  most  flourishing  health.  They  are  all  painless,  unless  they 
involve  a  bone  or  joint,  as  well  as  the  integument.  Sometimes  they  ac- 
company that  profound  cachexia,  produced  by  syphilis,  which  is  often  ob- 
served in  hospitals  upon  patients  with  visceral  disease  due  to  late  syphi- 
lis. The  cachexia  always  indicates  a  profound  alteration  of  some  of  the 
internal  organs,  when  it  appears  late  in  syphilis,  and  does  not  usually 
stand  in  any  immediate  relation  of  cause  to  the  eruption,  or  of  effect 
of  the  eruption,  be  it  rupia  or  ulcer,  for  the  same  cutaneous  lesions  may 
be  found  upon  patients  who  present  no  evidences  of  cachexia  whatsoever. 
Rupia,  however,  whether  the  patient  shows  cachexia  or  not,  indicates  a 


160 


THE    VEKEREAL    DISEASES. 


very  bad  quality  of  constitution,  and  calls  for  tonic  remedies  and  cod-liver 
oil,  as  well  as  for  the  mixed  treatment,  suitable  to  the  stage  of  the  dis- 
ease in  which  it  occurs. 


THE   PUSTULO-BULBOUS    SYPHILIDE    (BUPIA). 

A  scattered  bulbous  eruption  has  been  occasionally  encountered  in 
secondary  syphilis,  about  the  hands,  feet,  and  elbows,  but  it  is  met  with 
so  rarely  that  it  may  be  considered  a  pure  exception.  In  inherited  syphi- 
lis the  bulbous  lesion  is  not  uncommon,  and  it  will  be  described  in  connec- 
tion with  that  branch  of  the  subject. 

Rupia,  Fig.  12  (after  27,  Fox),  the  eruption  now  under  consideration, 
sometimes  starts  as  a  flat  pustule,  sometimes  as  a  bulla.  The  patient  may 
look  fat  and  seem  healthy,  but  he  is  not  so,  or  he  could  not  have  rupia. 
If  a  bulla  first  forms,  it  runs  on  quickly  to  suppuration,  and  blood  becomes 
mingled  with  the  pus.  The  first  lesion  thus  formed  scabs  over,  and  under 
the  scab  ulceration  commences,  yielding  pus,  which  raises  the  scab  from 
its  bed.  Meantime  around  the  scab  first  formed  an  epidermal  raised  ring 
appears,  filled  with  sero-pus.  This  dries  down  into  a  blackish  green  scab, 
enlarging  the  first  crust,  while  ulceration  goes  on  beneath  the  whole.  A 
new  sero-purulent  sub-epidermal  collar  forms  again  around  the  lesion,  and 
the  process  goes  on  repeating  itself. 

The  new  layers  of  pus  supplied  from  beneath,  raise  and  thicken  the 


FIQ.  12. 


scab,  and  if  this  process  continues  long  without  much  increase  in  the  area 
of  the  patch  by  the  formation  of  circumferential  bullae,  as  may  be  the  case, 
a  horn -may  be  formed  sometimes  an  inch  long  or  more,  and  in  any  case 
the  roughened  crust  comes  to  bear  a  close  resemblance  to  an  oyster-shell. 

This  oyster-shell  is  attached  at  the  borders,  but  not  by  its  under  sur- 
face, and  pressure  upon  it  generally  causes  pus  to  ooze  out  at  one  of  the 
edges  of  the  sore.  If  the  'scab  gets  detached  another  may  form,  or  the 
lesion  may  progress  as  an  open  or  a  partly  scabbed  ulcer,  with  a  livid  or 
pultaceous  base  and  sharp-cut  borders.  Sometimes  cicatrization  goes  on 
under  the  scab,  which  finally  falls  off,  leaving  a  livid  cicatrix,  generally 
covered  with  ridges,  drawn  and  puckered  in  part,  sometimes  surrounded 
by  a  coppery  areola,  sometimes  having  only  a  livid  border.  In  almost  all 
cases  the  scars  eventually  become  white. 

Treatment  must  be  tonic  in  all  ways  and  mixed  with  iodides  in  ex- 
cess. Local  treatment  of  the  ulcers,  when  the  scab  falls,  is  of  considera- 
ble value  (pp.  128,  137). 


SYPHILIS    OF   THE    SKIN. 


161 


THE   TERTIARY   PUSTULAR   SYPHILIDE. 

In  tertiary  disease  the  pustular  syphilide  is  found  in  two  forms.  As 
a  pustule  with  an  infiltrated  base,  ecthyma,  and  as  a  patch  of  pustules 
beneath  which  destructive  ulceration  goes  on. 

The  deep  ecthymatous  pustule  is  a  general  gummy  infiltration  of  the 
skin,  capped  with  a  pustule,  which  usually  goes  on  to  ulceration. 

The  gummatous  thickening  of  the  skin  is  obvious  in  the  case  of  single 
isolated  ecthymatous  lesions,  but  it  becomes  lost  as  the  single  lesion  ulcer- 
ates, or  the  patch  of  ecthymatous  pustules  spreads.  When  this  thick- 
ening is  present  it  exists  as  a  lurid,  painless,  hard  lump,  often  surrounded 
by  a  bronzed  areola,  especially 
upon  the  lower  extremity,  as  the 
isolated  ecthymatous  spot  gets  old. 

The  thick  green  crust  which 
forms  upon  the  top  of  an  ecthy- 
matous pustule  resembles  a  rupial 
crust.  Its  edges  are  thin,  and  fre- 
quently are  depressed  beneath  the 
level  of  the  surrounding  skin,  ma- 
king the  latter  look  like  a  setting 
which  holds  the  scab  in  place. 
These  scabs  are  quite  adherent, 
and  may  remain  attached  until  ci- 
catrization is  complete.  The  ec- 
thymatous lesions  of  the  patch  in 
Fig.  13  (113,  Fox)  are  partly  scab- 
bed, partly  cicatrized. 

The  cicatrix  of  a  single  deep 
ecthymatous  spot  is  the  typical 
syphilitic  scar,  smooth,  thin,  white, 
depressed,  non-adherent.  At  first 
it  is  livid,  and  it  remains  in  most 
cases  surrounded  for  a  long  time 
by  a  border  of  pigment. 

The  favorite  seat  of  deep  ecthy- 
ma is  the  lower  extremities — but 
it  may  be  found  anywhere  upon 
the  body,  and  is  not  uncommon  on 
the  face. 

When  several  ecthymatous  le- 
sions run  together,  an  ulcer  may 
result,  which  may  become  serpigi- 
nous,  and  creep   over  a  considerable  extent  of  surface,  often  getting  well 
on  one  side  as  it  advances  toward  the  other. 

In  ecthyma  the  mixed  treatment  is  appropriate,  together  with  mercu- 
rials locally  (pp.  128,  137). 

Ecthyma  does  not  necessarily  indicate  a  bad  condition  of  the  patient. 

The  pustular  syphilide  in  groups  generally  comes  on  late  in  syphi- 
lis. A  red  spot  appears,  which  quickly  becomes  covered  with  small  pus- 
tules. These  run  together  and  scab,  and  beneath  the  scab  ulceration 
goes  on.  As  the  ulcer  grows,  so  does  the  scab,  and  if  the  latter  falls  off, 
or  is  removed,  a  new  one  forms.  The  secretion  beneath  the  scab  is  scanty, 
and  the  crust,  therefore,  does  not  become  rupial. 
11 


Fis.  13. 


162 


THE    VENEKEAL   DISEASES. 


Fio.  14  (Pox,  40). 


Finally,  when  the  patch  has  reached  a  considerable  size  in  some  cases, 
the  new  pustules  around  the  edges  upon  the  livid  areola  cease  to  form, 
the  whole  patch  dries  up  and  contracts,  cicatrizing  under  the  crust.  When 

the  latter  falls,  a  livid  scar  is  left,  with 
a  bronzed  areola.  The  centre  whitens, 
the  areola  generally,  but  not  always,  dis- 
appears. 

A  serpiginous  ulcer  may  result  from 
this  lesion,  as  it  may  from  ecthyma,  or 
from  rupia. 

An  error  in  diagnosis  is  not  probable. 
The  pustular  scrofulide  generally  comes 
early  in  life,  and  the  lesion  with  its  ulcer 
have  different  characters. 

Treatment  is  mixed  internally,  with 
the  iodide  in  excess  (p.  137).  Local  treat- 
ment is  quite  effective  in  this  eruption, 
and  its  rapid  influence  is  much  to  be  de- 
sired, since  the  eruption  may  occupy  the 
face. 

The  syphilitic  tertiary  ulcer  is 
not  an  especial  affection.  It  is  a  second 
stage  of  rupia,  ecthyma,  patches  of  tu- 
bercles, or  of  pustules,  or  a  sequence  of 
gummy  infiltration,  or  of  gummy  tumor 
of  the  skin.  Figs.  14  and  15  indicate  favorite  sites  and  appearances  of 
syphilitic  tertiary  ulcers  ;  Fig.  16  represents  moderately  well  the  appear- 
ance of  typical  syphilitic  scars. 

The  ulcer  always  has  similar  characters,  whether  destroying  in  depth, 
or  running  superficially  up- 
on the  surface  (serpiginous 
ulcer).  The  ulcer  has  per- 
pendicular edges,  hard,  liv- 
id, (generally)  adherent  bor- 
ders, a  livid,  pultaceous  floor 
(sometimes  smooth  and  shin- 
ing), and  often  a  hard  base. 
These  lesions  are  painless  for 
the  most  part,  unless  they 
involve  the  periosteum  from 
being  situated  over  it,  as  on 
the  shin,  or  unless  they  be- 
come inflamed  from  injury, 
or  by  position,  as  on  the 
lower  extremity. 

The  syphilitic  ulcer  may 
remain  stationary,  it  may 
eat  downward,  exposing  a 
bone,  destroying  the  perios- 
team  and  leaving  a  piece  of  ^^ 

bare  bone  in  the  floor  of  the 

ulcer.  This  bone,  at  first  white,  becomes  black.  It  often  dies,  gradually 
separates  from  the  healthy  bone  beneath,  and  is  thrown  off.  The  deep, 
destructive  ulceration  which  deforms  the  nose  generally  follows  a  gum- 


SYPHILIS    OP   THE    SKIN". 


163 


my  tumor  or  gummatous  infiltration.     The  same  may  be  said  of  the  de- 
structive ulcer  of  the  penis. 

Serpiginous  ulcers  are  those  which  spread  superficially,  either  in  all  di- 
rections, or,  advancing  in  one  direction,  get  well  in  the  other. 

Around  joints,  and  on  the  lower  extremities,  syphilitic  ulcers  may  re- 
main for  years,  perhaps,  untreated,  until  the  end  of  life.  They  yield, 
however,  to  well-directed  internal  mix- 
ed treatment,  with  iodides  in  excess, 
and  to  intelligent  local  means,  pressure, 
mercurials,  iodoform,  etc.,  p.  130. 

Great  care  must  be  exercised  to  dis- 
tinguish a  tertiary  ulcer  upon  the 
tongue  or  lip  from  an  epithelioma, 
upon  the  penis  from  a  phagedenic 
chancroid  or  an  epithelioma,  upon  the 
nose  or  face  from  an  ulcerative  lupus 
or  a  rodent  ulcer.  The  peculiar  char- 
acters of  syphilitic  ulcers,  so  often  al- 
ready detailed,  ought  to  be  sufficient  to 
guide  to  a  diagnosis  in  most  cases.  In 
all  cases  of  doubt  the  touchstone  of 
treatment,  if  intelligently  applied,  will  clear  up  the  question  promptly. 
In  nearly  all  cases  of  tertiary  ulceration,  except  when  it  occurs  upon  the 
lower  extremities,  and  is  already  old,  and  when  it  comes  on  in  connec- 
tion with  profound  cachexia  ;  in  nearly  all  other  classes  of  cases  internal 
treatment  alone  is  promptly  effective  of  good  results,  although  local 
measures  may  greatly  aid  the  healing  of  the  sore. 


Fio.  16  (Fox,  110). 


GITMMA    OF    THE    SKIN. 

Tubercular  and  ecthymatous  patches  are  certainly  the  seat  of  gumma- 
tous infiltration.  There  is  also  a  true  gumma  of  the  skin,  which  appears 
as  a  general  infiltration,  and  another  form  which  takes  the  shape  of  a  cir- 
cumscribed tumor.  Either  form  may  ulcerate;  the  latter  habitually  does 
so  unless  arrested  by  treatment. 

Diffuse  gummatous  infiltration  of  the  skin  is  not  common.  It 
occurs  as  a  patch  of  livid  redness,  hard,  raised,  somewhat  scaly  on  the 
surface,  perhaps  for  a  long  time  smooth  and  shining.  Upon  this  surface, 
little  prominences  may  appear,  which  quickly  ulcerate.  The  ulcers  run 
together  and  behave  like  the  syphilitic  ulcers  already  described,  remain- 
ing stationary,  or  becoming  serpiginous,  but  not  destroying  in  depth. 
Rarely  the  patch  sinks  away,  leaving  a  general  thinning  of  the  skin  be- 
hind, but  no  distinct  scar,  as  such. 

Gummatous  infiltration  of  the  skin  presumably  precedes  all  ulceration 
of  the  serpiginous  sort,  whether  coming  on  as  a  sequence  to  rupia,  ecthyma, 
or  any  other  lesion;  and  the  infiltrated  patches  bearing  tubercles,  scales,  or 
pustules,  owe  their  infiltration  undoubtedly  to  an  analogous  pathological 
condition. 

The  gumma  proper  of  the  skin  is,  strictly  speaking,  the  syphilitic 
tubercle.  The  gummy  tumor,  yielding  an  ulcer  on  the  skin,  is  generally 
a  localized  accumulation  of  gummatous  cells  in  the  subcutaneous  con- 
nective tissue.  These  are  first  noticed  as  hard,  shot-like  bodies  beneath 
the  skin.  They  are  absolutely  insensitive  upon  manipulation.  The  skin 


164  THE    VENEREAL   DISEASES. 

is  freely  movable  over  them,  and  they  themselves  are  not  attached  firmly 
to  the  surrounding  or  underlying  parts.  In  this  state  a  subcutaneous 
gumma  may  remain  for  months,  and  sometimes  gradually  disappear,  even 
without  treatment,  leaving  no  apparent  trace  of  its  former  existence. 
Generally,  however,  unless  treatment  intervenes,  the  lump  gradually  en- 
larges, attaches  itself  to  all  the  surrounding  tissues,  softens  centrally,  and 
the  detritus  of  gummy  matter  slowly  but  surely  ulcerates  its  way  to  the 
surface.  . 

The  skin  over  the  tumor,  in  such  a  case,  becomes  livid  and  thin,  the 
soft  central  spot  finally  gives  way,  and  the  contents  of  the  tumor  escape, 
not  as  pus,  but  as  a  more  or  less  thick,  honey-like  material,  of  a  grayish 
yellow  color  tinged  with  green,  and  mingled  with  more  or  less  blood. 
This  detritus  is  composed  of  broken-down  gummatous  cells,  and  the  de- 
bris of  the  intervening  tissue  which  was  infiltrated  with  those  cells. 
After  discharging,  the  gumma  remains  open  as  a  deep  syphilitic  ulcer, 
which  generally  gradually  heals,  leaving  a  characteristic  scar.  Subperios- 
teal  gummata  are  often  painful.  They  may  remain  long-  stationary,  and, 
finally  ulcerating,  be  followed  by  the  death  of  large  portions  of  bone,  gen- 
erally the  superficial  layers,  which  become,  later,  slowly  necrotic. 

Gummata  of  the  nose  are  very  apt  to  lead  to  perforation,  destruction 
of  bone,  and  permanent  deformity.  Gummata  occur  over  the  whole  body. 
Local  traumatisms  seem  sometimes  to  call  them  into  existence. 

Wherever  the  gumma  occurs,  the  tissue  which  is  implicated  is  certain 
to  be  destroyed.  The  new  round  and  fusiform  cells  are  usually  incapable 
of  organization  beyond  a  certain  point,  and  when  the  tumor  lias  reached 
a  certain  size  it  deliquesces,  and  its  wasted  elements  and  the  tissues  lying 
between  them  seek  a  way  to  the  surface,  or  they  are  absorbed — first  the 
watery,  later  the  solid  parts — through  the  instrumentality  of  granulo-fatty 
degeneration.  The  remains  of  the  solid  parts  may  become  cretaceous  and 
encysted,  and  continue  in  this  state  indefinitely.  Sometimes  gummatous 
exudation  is  entirely  absorbed,  leaving  behind  a  cyst  containing  a  little 
fluid.  This  termination  is  exceedingly  rare. 

Sometimes  gummy  deposit  undergoes  fibrous  transformation  (around 
the  dura  mater,  interstitially  in  the  different  organs,  notably  the  lungs), 
but  this  peculiar  form  of  retrogressive  metamorphosis  does  not  seem  to 
obtain  in  the  case  of  gummy  tumor  of  the  skin. 

Treatment  of  gumma,  wherever  it  occurs  in  the  body  in  the  form 
of  a  distinct  tumor,  is  by  the  iodide  of  potassium;  all  the  iodides  are  the 
natural  specific  enemies  of  gummatous  deposit. 


CHAPTER  IX. 

SYPHILIS   OF   MUCOUS   MEMBRANES. 

Erythematous,  TJlcerative,  Mucous,  and  Scaly  Patches,  and  Guminatous  Ulcers  of  the 
Mucous  Membranes  of  the  Mouth,  Nose,  and  Fauces. 

THE  mucous  membranes  of  the  body,  as  well  as  the  outside  integument, 
are  affected  by  various  lesions  in  the  course  of  syphilitic  disease.  These 
lesions  are  few  in  number.  Some  of  them  occur  early,  some  late  in  the 
disease,  others  at  all  times.  They  are,  in  the  mouth,  throat,  and  nose: 

1.  Erythematous  patches  with  erosions  and  superficial  ulcers  (occurring 
at  all  times). 

2.  Mucous  patches  (occurring  in  the  typical  form  only  during  second- 
ary syphilis). 

3.  Scaly  patches  (occurring  only  late  in  syphilis). 

4.  Gummatous  ulcers  (occurring  only  late  in  syphilis). 

EEYTHEMATOUS    PATCHES,    EROSIONS    AND    SUPERFICIAL    ULCERS. 

These  lesions,  most  notable  during  the  earliest  general  outbreak  of 
syphilis,  may  yet  appear  in  modified  form  throughout  the  disease,  either 
in  connection  with  the  various  eruptions,  or  independently.  Often,  during 
the  syphilitic  fever,  when  the  lymphatic  glands  behind  the  neck  just  begin 
to  be  perceptible,  before  any  eruption  can  be  made  out  upon  the  trunk, 
careful  inspection  will  show  that  the  fauces  are  covered  with  a  uniform 
redness,  suggestive  of  a  common  sore  throat.  The  main  difference  be- 
tween this  erythema  and  ordinary  sore  throat  is  that  in  the  former  the 
blush  often  occupies  more  particularly  the  under  surface  of  the  soft  palate 
and  is  apt  to  be  very  distinctly  punctate  in  character  (recalling  the  ery- 
thema of  scarlatinal  sore  throat).  This  redness  may  extend  out  of  sight 
up  into  the  nares  and  down  below  the  pharynx.  The  Schneiderian  mem- 
brane may  be  pretty  uniformly  involved,  as  in  a  common  cold.  More  or 
less  tonsillar  hypertrophy  accompanies  this  condition. 

With  this  erythema  the  patient  generally  complains  of  more  or  less 
pain,  and  he  may  be  temporarily  deaf,  or  lose  his  voice  for  a  few  days. 

In  connection  with  this  redness,  excoriations  may  occur  upon  the  lips, 
upon  the  throat,  along  the  edges,  upon  the  dorsum,  and  at  the  tip  of  the 
tongue.  These  excoriations,  however,  have  nothing  characteristic  about 
them.  They  are  much  more  apt  to  come  on  at  indefinite  periods  late  in 
the  disease.  Little,  yellow,  round,  superficial  ulcers,  behind  the  lips,  or  on 
the  tip  or  sides  of  the  tongue,  are  matters  of  daily  observation  in  a  vene- 
real clinique,  at  all  dates  of  syphilis. 

Peculiarly  common  after  the  lapse  of  several  years,  is  an  angry  red- 
dened excoriation  of  the  sides  of  the  tongue,  far  back  near  the  root,  on 


166  THE   VENEREAL    DISEASES. 

both  sides.  This  may  exist  for  months  without  ulcer  or  scaly  patch.  It 
is  kept  up  by  smoking,  and  by  rough  edges  of  teeth,  but  occasionally  oc- 
curs without  the  aid  of  either  of  these  exciting  causes.  All  of  these  ex- 
coriations are  likely  to  be  somewhat  sensitive,  especially  that  form  occur- 
ring on  the  sides  of  the  tongue,  during  the  second  year  and  later,  in  which 
the  papillae  seem  to  be  angry  and  irritated. 

Local  treatment  is  of  the  first  importance  in  all  mouth  and  throat 
lesions  belonging  to  this  class.  These  local  means  have  been  detailed  in 
connection  with  the  discussion  on  general  treatment,  p.  130. 


MUCOUS    PATCHES. 

The  typical  mucous  patch  is  a  lesion  found  only  in  syphilis  and  in 
perfection,  usually,  only  in  early  syphilis.  It  may  come  on  simultaneously 
with  the  first  erythema  of  the  throat,  and  continue  to  appear  from  time 
to  time  throughout  the  secondary  period;  but  it  is  commonly  seen  in 
greatest  perfection  in  connection  with  the  general  papular  syphilide  of 
the  integument.  The  forms  occurring  late  in  the  secondary  and  during 
the  tertiary  period  are  usually  scaly  patches  and  excoriations,  resembling 
the  squamous  syphilide  more  than  the  papule.  The  true  mucous  patch 
is  a  flat  papule  with  a  sodden  epithelium  capping  it.  Its  connection 
with  the  papule  has  been  touched  upon  in  the  description  of  the  flat  pap- 
ular syphilide,  where  it  was  shown  how  any  flat  syphilitic  papule,  kept 
moist  and  sodden,  becomes  a  mucous  papule  of  the  skin. 

Cornil l  has  recently  studied  the  "  opaline  mucous  tubercle  "  minutely. 
As  found  upon  the  tonsil,  he  relates  that  the  ]  apillse  are  hypertrophied, 
the  epithelium  thickened,  the  deeper  tissues  infiltrated  with  new  cells. 
In  the  superficial  epithelial  cells  he  found  cavities  sometimes  containing 
pus-corpuscles  and  numbers  of  nests  of  pus-cells  between  the  epithelial 
scales.  These  little  abscesses  open  from  time  to  time  upon  the  surface, 
and  yield  the  secretion  of  the  mucous  patch.  When  many  of  the  little 
abscesses  break  down  together  and  become  confluent,  a  disintegrated  ul- 
cerated surface  remains.  Upon  the  surface  of  this  ulcerated  mucous 
patch  there  may  be  a  false  membrane,  but,  according  to  Cornil,  this 
membrane  does  not  contain  the  microscopic  organism  found  in  diphthe- 
ritic membrane.  The  closed  follicles,  when  the  tonsils  are  the  seat  of 
mucous  patches,  are  inflamed,  the  whole  gland  congested  and  hyper- 
trophied. 

Clinically  speaking,  the  mucous  patch  is  a  round,  or  irregularly  round- 
ed, raised  patch  of  a  dirty  white  color,  sometimes  red  and  granulating, 
covered  with  a  more  or  less  puriform  secretion.  In  size,  they  vary  from 
a  point  to  large,  irregular  surfaces,  generally  produced  by  the  confluence 
of  several  patches,  and  capable  of  reaching  almost  any  dimensions. 
They  occur  about  the  tonsils,  and  upon  all  the  pharynx,  within  the  lips, 
or  upon  the  tongue,  within  the  nose,  and  down  in  the  larynx  and  trachea, 
where  they  have  been  repeatedly  observed  with  the  laryngoscope.  Un- 
less ulcerated  or  attended  by  surrounding  erythema,  they  are  painless. 
Often  the  patient  is  unconscious  of  their  existence.  When  they  ulcerate 
or  inflame,  they  may  become  quite  painful. 

They  relapse  frequently,  and  continue  to  come  out  upon  the  mucous 

OA  ' .Communication  to  the  French  Academy.     Referred  to  in  London  Lancet,  August 
**»  Io7o. 


SYPHILIS    OF   THE   MUCOUS    MEMBRAISTES.  167 

membranes,  either  spontaneously,  or,  more  often,  as  the  result  of  local 
irritation — a  rough  tooth,  smoking. 

Mucous  patches  do  not  leave  any  scars  unless  they  ulcerate,  and  even 
then,  the  ulceration  being  superficial,  the  scars  are  not  well  marked. 

Something  has  already  been  said  about  mucous  patches  on  the  skin, 
at  p.  148,  in  connection  with  the  description  of  the  papular  syphilide.  In 
addition,  it  may  be  said,  when  there  is  present  a  generalized,  flat,  papular 
syphilide,  any  of  these  papules  may  become  a  mucous  patch  upon  the 
skin,  if  subjected  to  heat  and  moisture.  Hence,  the  mucous  patches 
about  the  scrotum,  the  anus,  between  the  toes,  in  the  groin,  about  the 
umbilicus  in  fat  persons,  and  under  the  breast  in  the  female.  Under  the 
prepuce,  in  the  vagina  in  the  female,  and  about  the  anus,  mucous  patches 
often  arise  independently  of  any  general  eruption.  They  are  not  uncom- 
mon upon  the  delicate  skins  of  children.  In  short,  wherever  two  surfaces 
lie  together,  especially  if  there  be  any  secretion,  and  the  parts  be  allowed 
to  become  dirty,  if  the  patient  is  in  the  early  stages  of  syphilis,  mucous 
patches  may  be  looked  for.  If  the  secretions  from  these  patches  be  re- 
tained, they  undergo  prompt  decomposition,  and  emit  a  foul  odor.  They 
may  ulcerate  about  the  anus,  or  between  the  toes,  and  become  very  pain- 
ful. Vegetations  may  spring  up  around  them,  and  they  themselves  may 
grow  up  so  as  to  be  large,  pedunculated,  flat  warts  (condyloma  lata). 
It  cannot  be  too  often  repeated  that  the  secretions  of  mucous  patches  are 
laden  with  the  poison  of  syphilis,  and  as  capable  of  transmitting  the  dis- 
ease as  is  the  secretion  of  a  chancre.  A  man  or  woman,  with  a  mucous 
patch  upon  or  just  within  the  lip,  is  far  more  dangerous  to  the  community 
as  a  focus  of  disease  than  two  or  three  individuals  with  chancre.  The 
local  treatment  of  mucous  patches,  both  of  the  skin  and  of  mucous  mem- 
branes, is  very  important.  It  may  be  found  under  the  head  of  general 
treatment,  p.  129. 


SCALY  PATCHES. 

Scaly  patches  upon  the  throat,  tongue,  and  the  inside  of  the  lips  and 
cheeks,  are  very  common  during  the  second  year  of  syphilis  and  later. 
They  take  the  place  of  mucous  patches,  and  are  frequently  called  by  that 
name.  They  may  occur  early  enough  in  syphilis  to  be  associated  with 
the  true  mucous  patch,  but  their  natural  position  is  later  in  the  disease. 

They  appear  as  flat,  rounded,  irregularly  shaped  patches  of  a  bluish 
white  color  anywhere  within  the  mouth,  but  by  preference  at  the  angles 
of  the  lips,  and  on  the  tip,  sides,  and  dorsum  of  the  tongue.  They  are  quite 
flat  and  insignificant-looking;  but  the  patient  learns  to  know  them,  and  they 
cause  him  much  uneasiness.  They  are  manifestly  due  to  epithelial  thicken- 
ing, and  their  whiteness  depends  upon  this  fact.  Sometimes  a  limited  patch 
(particularly  under  the  tongue)  will  take  on  extensive  overgrowth  and 
yield  an  adherent  white  patch  of  epithelium  as  thick  as  a  piece  of  blotting- 
paper,  looking  exactly  like  the  disease  called  tylosis  or  icthyosis  of  the 
tongue.  Sometimes  these  occur  also  in  the  angles  of  the  mouth  due  to 
syphilis.  Sometimes  the  entire  dorsum  of  the  tongue  becomes  covered  with 
this  scaly  syphilide,  giving  it  a  mottled  white  and  blue-white  appearance 
which  is  not  simulated  by  any  other  disease  with  which  I  am  familiar. 

These  patches  cannot  be  scraped  off.  They  are  not  ulcers.  If  roughly 
handled  they  bleed.  They  are  generally  sensitive,  although  not  seemingly 
inflamed,  and  when  large  patches  exist  in  the  mouth  the  contact  of  condi- 


168  THE    VENEBEAL   DISEASES. 

merits  causes  pain,  and  eating  is  only  accomplished  at  the  expense  of  great 
discomfort.  Occasionally  one  of  these  scaly  patches  ulcerates,  but  this 
is  not  the  rule. 

These  patches  occur  also  in  the  vulva. 

Smoking,  chewing  tobacco,  all  irritants  applied  to  the  mouth,  the 
rough  edges  of  teeth,  lack  of  cleanliness,  are  exciting  causes  of  the  scaly 
syphilide  of  the  mouth.  These  patches  often  occur  long  after  all  signs  of 
syphilis  have  disappeared,  and  they  yield  to  local  treatment  and  do  not 
call  for  a  renewal  of  internal  remedial  measures.  They  do  not  necessa- 
rily indicate  that  the  malady,  perhaps  long  latent,  is  again  to  become  ac- 
tive; but  they  do  indicate  that  the  syphilitic  diathesis  is  not  yet  dead. 

These  patches  sometimes  so  closely  resemble  true  ichthyosis  of  the 
tongue,  that  a  diagnosis  by  the  physical  characters  alone  is  impossible. 
Generally  the  icthyosis  has  been  of  longer  duration  and  is  less  sensitive 
than  the  syphilitic  patch. 

The  mingled  excoriations  and  scaly  patches  found  not  infrequently 
upon  the  tongue  and  in  the  mouth  of  persons  having  a  tendency  to  dry 
eczema,  once  seen,  could  not  be  mistaken  for  a  scaly  syphilide.  This  con- 
dition is  not  common,  and  is  encountered  most  often  in  the  mouths  of  anae- 
mic women.  It  is  almost  invariably  aggravated  at  each  menstrual  epoch. 
Nothing  of  the  kind  obtains  in  syphilitic  scaly  disease  of  the  tongue. 


GTJMMATOUS    ULCERS    OF    THE    MOUTH    AND    FAUCES.1 

Besides  the  slight  round  ulcers  and  the  irregular  erosions  of  the  mouth 
common  to  the  whole  period  of  syphilis,  three  other  forms  of  ulcer  claim 
description  here,  namely:  the  stationary,  chronic,  infiltrated  ulcer;  the 
serpiginous  ulcer;  and  the  ulcerative  gummy  tumor.  All  of  these  occur 
late  in  syphilis.  The  infiltrated  ulcer  is  also  found  early  in  the  disease. 

The  deep,  ragged,  brawny  ulcer  of  the  tonsil,  found  in  syphilis, 
may  be  encountered  early  and  late  in  the  disease,  alone  and  coincidently 
with  other  symptoms.  It  may  originate  in  a  mucous  patch  in  early  syph- 
ilis, or  may  start  spontaneously  in  both  stages  of  the  malady.  The  ulcer 
occupies  the  tonsil  by  preference,  usually  is  oval,  with  its  long  axis  paral- 
lel to  that  of  the  tonsil.  It  may  extend  over  upon  either  of  the  half  arches, 
or  upon  the  soft  palate.  It  may,  indeed,  occur  spontaneously  at  the  an- 
gles of  the  mouth,  inside  the  cheeks,  or  elsewhere.  The  base  is  pulta- 
ceous,  the  borders  cut  away,  generally  livid,  sometimes  pink,  usually  hard 
and  accompanied  by  a  sodden,  livid  condition  of  cedematous  infiltration  of 
all  the  surrounding  tissues. 

The  ulcer  remains  stationary  or  progresses  slowly.  It  often  occasions 
great  pain,  especially  upon  swallowing,  and  is  apt  to  be  accompanied  by 
a  feverish  state  of  the  body,  a  furred  tongue  red  at  the  tip,  and  often  by 
considerable  continuous,  spontaneous  pain,  especially  in  early  syphilis. 

But  little  tissue  is  destroyed  by  these  ulcers,  and  the  resulting  scars 
are  not  deep.  Secretions  from  such  ulcers  in  early  syphilis  are  conta- 
gious. 

The  serpiginous  ulcer  occurs  later  in  the  disease,  and  is  manifestly 
a  gummatous  infiltration.  The  seat  of  these  ulcers  is  varied.  The  edge, 
er  the  upper  part  of  the  soft  palate,  is  not  infrequently  involved,  and 

1  Gummata  of  the  tongue  will  be  considered  under  the  head  of  syphilis  of  the  di- 
gestive organs. 


SYPHILIS    OF   THE   MUCOUS    MEMBRANE'S.)  169 

quite  often  the  back  of  the  pharynx,  high  up,  is  the  seat  of  disease. 
More  rarely  other  parts  of  the  mouth  are  affected.  Not  infrequently, 
with  this  form  of  ulcer  in  the  pharynx,  the  larynx  is  the  seat  of  tertiary 
syphilitic  disease. 

These  tertiary,  serpiginous  ulcers  do  not  constantly  advance.  They 
sometimes  remain  stationary  for  months,  even  years,  upon  the  pharynx, 
giving  very  little  pain,  causing  the  patient  to  spit  up  a  few  bloody  scabs 
in  the  morning,  and  attended  by  a  dryness  and  an  uncomfortable  feeling 
in  the  throat.  Sometimes  it  is  necessary  to  hook  up  the  soft  palate  with 
a  carved  probe,  in  order  to  find  such  an  ulcer,  or  to  use  the  laryngoscopic 
mirror. 

Sometimes  these  ulcers  advance  rapidly,  eating  off  the  uvula  in  a  few 
days,  and  destroying  large  portions  of  the  soft  palate  by  eating  it  away 
from  the  edge  inward.  When  such  ulcers  get  well  they  occasionally  leave 
the  pharynx  much  distorted  by  cicatrices. 

The  gummy,  stationary,  or  serpiginous  ulcer  of  the  pharynx  generally 
goes  with  a  bad  type  of  disease,  and  is  often  associated  with  profound 
syphilitic  cachexia. 

The  local  treatment  of  this  form  of  ulcer  is  not  very  important.  Fu- 
migations are  of  some  service,  and  the  iodides  internally  are  impera- 
tively called  for.  Cleanliness  is  of  great  value,  and  the  abandonment  of 
tobacco. 


GUMMY  TUMOR  OF  THE  MOUTH. 

Gummy  tumors  may  appear  anywhere  within  the  mouth.  Gumma  of 
the  tongue  will  be  described  later.  The  gumma  of  the  hard  or  soft  palate 
is  not  uncommon,  and  is  very  dangerous  on  account  of  the  damage  it  is 
likely  to  cause  if  unchecked. 

A  subrnucous,  round,  insensitive  swelling  first  appears,  not  attended 
by  pain.  Perhaps  the  gummatous  infiltration  is  diffuse  over  a  limited 
area,  and  not  concentrated  into  a  single  nodule.  The  growth  of  the  gum- 
matous material  may  be  slow  at  first,  but  it  is  often  rapid  from  the  start. 

When  the  tumor  has  reached  a  certain  size,  the  mucous  membrane 
over  it  becomes  osdematous  and  rapidly  gives  way,  disclosing  a  cavity 
which  constitutes  a  gummatous  .ulcer  like  that  seen  upon  the  skin,  with 
perpendicular  edges  and  a  deeply -situated  grayish  yellow  floor.  The  dif- 
fuse infiltration  in  a  similar  manner  may  soften  suddenly,  and  rapid  ulcer- 
ation  sweep  away  quite  an  expanse  of  tissue. 

The  gummatous  ulcer  once  formed  destroys  all  the  tissues  in  its  path 
which  have  been  infiltrated.  Bone  and  cartilage  offer  no  barriers  to  its 
Kiarch.  Extensive  destruction  of  tissue  may  ensue  unless  treatment  inter- 
vent,  and  large  portions  of  the  roof  of  the  mouth  may  be  sacrificed  to  ob- 
scurity of  diagnosis  or  lack  of  therapeutical  boldness. 

The  odor  of  the  ulceration  in  these  cases,  when  the  bone  is  involved, 
has  something  in  it  which  is  nearly  pathognomonic.  The  same  may  be 
perceived  when  the  bones  of  the  nose  are  involved  in  gummatous  syphili- 
tic disease. 

Whether" these  extensive  throat-ravages,  caused  by  syphilis,  may  not 
also  be  sometimes  due  to  other  pathological  conditions  (scrofula,  lupus), 
has  long  been  a  question.  My  personal  experience  inclines  me  to  the 
opinion  that  syphilis  is  their  sole  and  only  cause;  but  I  am  very  well 
aware  that  there  is  excellent  authority  for  the  opinion  that  a  scarred  phar- 


170  THE   VENEREAL   DISEASES. 

ynx,  like  that  so  often  seen  in  syphilis,  inherited  or  acquired,  may  be  due 
to  the  previous  existence  of  lupus  of  the  pharynx,  or  of  tubercular  ulcer- 
ation  which  has  gotten  well. 

Atkinson,  of  Baltimore,  in  connection  with  an  excellent  case  of  ignor- 
ed syphilis,  has  reviewed  this  question  very  ably,  in  the  January  (1879) 
number  of  the  American  Journal  of  Medical  Sciences. 

The  local  treatment  of  gummatous,  destructive  ulcers  of  the  mouth 
and  fauces  is  unimportant.  The  unsparing  internal  use  of  the  iodides  is 
the  patient's  main  salvation.  Any  temporizing  with  such  a  case,  or  at- 
tempts to  cure  by  local  means,  is  unjustifiable.  Sometimes  enormous 
doses  of  the  iodides  are  borne  by  these  throat  cases.  When  cachexia  is 
far  advanced,  some  of  them  become  incurable. 


CHAPTER  X. 

SYPHILIS   OF  LYMPHATIC  GLANDS, 

OF    HAIEY   PAETS,    OF     THE     FINGEKS     AND     TOES,    OF     MUSCLES,    TENDONS, 
APONEUBOSES,    BUBS^E,    JOINTS,    BONES,    AND    CARTILAGE. 

Epitrochlear  and  Post-cervical  Indolent  Glandular  Engorgement. — Syphilitic  Alopecia. 
— Syphilitic  Onychia  and  Paronychia. — Dactylitis. — Syphilitic  Myostitis,  Conges- 
tive, Diffuse,  Gummatous. — Syphilis  of  Tendons,  Sheaths  of  Tendons,  and  Apon- 
euroses. — Syphilis  of  the  Bursse. — Syphilis  of  Ligaments  and  Joints. — Syphilis  of 
Bones. — Osteocopic  Pains. — Nodes,  Dry  Caries,  Gummy  Tumor  of  Bone. — Mercury 
as  a  Cause  of  Bone  Disease. — Syphilis  of  Cartilage. 

As  has  already  been  stated,  the  lymphatic  glands  receiving  the  absorb- 
ents from  the  region  occupied  by  the  initial  lesion  of  syphilis  undergo 
indolent  engorgement.  Then  follows  a  rest  (second  incubation  period), 
and  then  general  syphilis. 

At  the  commencement  of  general  syphilis,  usually  before  the  outcrop 
of  any  general  eruption,  certain  glands  become  indolently  engorged  and 
constitute  valuable  corroborative  evidence  of  the  syphilitic  nature  of  any 
other  symptom  which  may  subsequently  appear.  Occasionally,  all  the 
lymphatic  glands  in  the  body  seem  to  undergo  slight  enlargement  at  this 
period,  but  such  changes  are  not  pathognomonic. 

The  glands  which  are  of  clinical  value  in  the  diagnosis  of  general  syph- 
ilis are  the  epitrochlear  and  the  posterior  superficial  chain  of  the  post- 
cervical  glands,  especially  the  highest  two  of  the  chain,  those  lying  on  the 
occipital  bone,  one  on  either  side  of  the  nucha.  The  post-aural  glands 
are  also  often  involved,  and  the  lateral  glands  in  the  neck,  but  they  mean 
nothing  especial. 

The  enlargement  of  these  epitrochlear  and  post-cervical  glands  is  not 
due  to  any  eruption,  as  is  so  often  stated  in  text-books.  Truly,  the  exist- 
ence of  an  eruption  may  intensify  their  hardness  and  increase  their  size; 
but  it  is  very  common  to  find  them  in  a  typical  state  of  indolent  engorge- 
ment, when  no  eruption  whatsoever  has  occupied  the  surface  from  which 
their  absorbent  radicles  are  derived.  For  the  post-cervical  glands  it  may 
be  objected  that  the  eruption  is  overlooked  in  the  hair;  but  this  surely 
cannot  be  said  of  the  epitrochlear  glands,  since  the  palms  and  forearms  can 
be  minutely  inspected.  It  is  certainly  the  free  poison  in  the  blood  which 
effects  the  indolent  engorgement  of  these  glands.  Why  these  particular 
glands  are  especially  modified  by  the  disease,  no  one  has  attempted  to  ex- 
plain. Some  of  the  internal  lymphatic  glands  are  also  involved  in  the 
earlier  periods  of  syphilis,  as  has  been  proved  by  post-mortem  examina- 
tions— Biirensprung,  Virchow.  By  pressure  of  glands  so  enlarged,  an 
attempt  has  been  made  to  explain  the  jaundice  occurring  early  in  second- 
ary syphilis. 


172  THE   VENEREAL    DISEASES. 

The  glands  themselves  need  a  little  description. 

They  are  as  hard  as  bullets  under  the  skin,  freely  movable  in  all  direc- 
tions, and  not  adherent  to  the  skin.  The  integument  over  them  is  not 
colored,  and  they  are  insensitive  to  pressure,  with  occasional  excep- 
tions, when  they  first  come  out.  They  rarely  get  larger  than  a  good-sized 
pea. 

The  duration  of  these  glandular  indurations  is  quite  protracted.  They 
appear  about  six  weeks  after  chancre,  and  habitually  last  for  months — but 
little,  if  at  all,  affected  by  treatment.  Sometimes  a  trifling  enlargement 
continues  permanently,  but  all  the  characteristic  syphilitic  features  of  the 
glands  disappear  during  the  first  year.  Consequently,  one  should  not  ex- 
pect the  corroborative  evidence  of  these  glands  in  the  case  of  an  eruption 
supposed  to  be  syphilitic,  occurring  later  than  the  end  of  the  first  year 
after  chancre. 

I  have  seen  symmetrical  suppuration  of  the  epitrochlear  glands  coming 
on  spontaneously  and  having  no  connection  with  syphilis,  but  I  have 
never  seen  the  indolent  engorgement  of  syphilis  above  described  go  on  to 
suppuration. 

Other  glandular  lymphatic  engorgements  do  occur  constantly  in  syphi- 
lis in  various  regions.  In  connection  with  mouth  lesions,  or  spontane- 
ously, one  or  more  glands  of  the  neck  indifferently  situated  may  suddenly 
swell  up,  remain  enlarged  for  a  long  time,  perhaps  finally  suppurating,  or 
abscess  may  promptly  form  in  a  gland,  running  on  to  a  speedy  opening  and 
discharge.  Such  abscesses  in  early  syphilis  generally  get  promptly  well. 
Later,  in  scrofulous  patients,  they  remain  open  and  partake  of  the  mixed 
characters  of  scrofulous  and  syphilitic  ulcers,  getting  well  very  slowly, 
and  yielding  a  scar  possessing  the  mixed  characters  of  syphilitic  and 
scrofulous  scars.  I  have  seen  such  an  ulcer  upon  a  patient  which  had  lasted 
more  than  a  year.  The  patient  had  had  a  crop  of  glands  successively  ul- 
cerating, the  attack  having  lasted  him  five  years  when  I  first  saw  him. 
This  long  duration  of  his  trouble  had  been  due  to  inappropriate  treat- 
ment, for  he  promptly  rallied  after  efficient  means  had  been  employed. 

Sometimes  these  glandular  enlargements  reach  a  great  size,  soften, 
but  fail  to  discharge,  and,  not  being  opened,  their  contents  dry  up  and  are 
absorbed,  a  caseous,  cretified  mass  being  left  behind. 

These  same  changes  in  the  lymphatic  glands  may  occur  in  the  groin, 
axilla,  and  elsewhere,  but  are  most  common  in  the  neck. 

Finally,  tertiary  glandular  gummata  are  encountered  in  various  glands, 
internal  as  well  as  external,  which  may  ulcerate  externally,  forming 
gummatous  ulcers,  and  may  disappear  by  absorption,  especially  in  re- 
sponse to  treatment.  The  abdominal  glands  will  be  referred  to  again  in 
connection  with  visceral  syphilis,  and  the  consideration  of  syphilis  of  the 
spleen  and  of  the  supra-renal  capsules  will  be  more  appropriate  there. 
Lancereaux  speaks  of  enlargement  and  fatty  degeneration  of  the  thyroid 
body,  due  to  syphilis,  and  gummy  tumors  have  been  found  in  it. 


SYPHILIS    OF    THE    HAIRY    PARTS. 

The  alopecia  of  syphilis  is  a  feature  of  early  secondary  disease,  very 
often  observed  in  connection  with  syphilitic  fever  and  with  the  first  erup- 
tion. It  varies  greatly  in  degree,  being  generally  quite  moderate  and  con- 
fined to  the  scalp,  from  which  it  thins  out  the  hairs  to  a  greater  or  less 
extent,  while  occasionally  it  is  very  severe,  implicates  the  whole  body, 


SYPHILIS    OF   LYMPHATIC    GLANDS,  ETC.  173 

and  perhaps  causes  the  shedding  of  all  the  hairs,  even  down  to  the 
lanugo. 

This  shedding  of  the  hair  in  early  syphilis  is  a  mere  accident,  and  not 
intrinsically  a  syphilitic  symptom.  It  is  the  result  of  the  anaemia  of  early 
syphilis,  and  is  due  to  a  failure  of  a  full  supply  of  nutrition  to  the  hair- 
papillae.  The  hairs  dry  up,  lose  their  lustre,  and  numbers  of  them  thin 
out  just  as  they  do  after  scarlet  or  typhoid  fever.  The  scalp  is  either 
unaltered  or  covered  with  fine  scales  (pityriasis  alba),  or  with  masses  of 
sebaceous  matter  mixed  with  scales  (seborrhoea),  with  which  the  follicles 
around  the  hairs  are  stuffed.  This  loss  of  hair  is  never  permanent  when 
occurring  in  a  young  person. 

Later  in  syphilis  from  cachexia,  there  may  be  a  similar  thinning  of 
the  hair,  and  in  these  cases  the  hair  is  less  apt  to  grow  again. 

Finally,  in  cases  of  ulcerative  disease,  involving  the  hair-papillae  and 
destroying  them,  localized  areas  of  baldness  ensue,  which  are  necessarily 
perpetual. 

The  treatment  of  syphilitic  alopecia  is  a  general  treatment  of  syphi- 
lis— the  treatment  of  that  stage  in  which  the  alopecia  occurs.  There  is 
much  value  in  mercury  both  as  a  preventive  to  the  fall  of  hair,  and  to 
arrest  the  fall  after  it  has  commenced  in  the  alopecia  of  early  syphilis. 
The  cachectic  form  occurring  later  generally  calls  for  mixed  treatment 
combined  with  tonics. 

One  fact  must  be  impressed  upon  a  patient  who  demands  a  cure  for 
his  alopecia.  At  the  moment  of  his  application,  many  hairs  are  already 
dead,  which  still  adhere  to  the  head.  They  are  retained  in  connection 
with  the  scalp  by  the  root-sheaths,  but  are  no  longer  united  to  their  pa- 
pillae. These  hairs  are  doomed.  No  power  on  earth  can  preserve  them, 
and  the  sooner  they  are  out  the  better,  for  the  follicle  will  the  sooner  be 
ready  to  produce  a  new  hair.  Hence  the  patient's  folly  maybe  made  clear 
to  him,  when  he  objects  to  brushing  his  hair  or  washing  his  scalp,  on  the 
ground  that,  when  he  does  this,  his  hair  comes  out  in  handfuls.  Let  it 
come.  These  hairs  must  fall  out.  The  patient  deceives  himself  by  sup- 
posing that  he  is  injuring  his  prospects  by  brushing  the  dead  hairs  away. 
No  amount  of  brushing  or  washing  will  dislodge  a  healthy  hair,  and  the 
unhealthy  ones  call  for  speedy  removal. 

Consequently  the  patient  should  be  told  to  wash  his  scalp  thoroughly 
once  or  twice  a  week,  either  with  soap,  or  with  borax  3  i-  to  the  §  ij.  of 
hot  water,  or  with  liquor  ammoniae,  a  drachm  to  the  pint  of  hot  water, 
according  to  the  dirtiness  of  the  scalp  and  the  amount  of  seborrhceal  exu- 
dation which  it  is  desired  to  remove.  Rather  hard  brushing  with  moder- 
ately stiff  brushes  is  to  be  recommended. 

Finally,  a  stimulating  lotion  should  be  rubbed  every  night,  in  small 
quantities,  well  upon  the  scalp,  and  into  the  follicles  under  the  hair.  Such 
lotions  add  a  little  to  the  chance  of  preserving  the  vitality  of  some  of  the 
hairs  whose  life  is  only  threatened,  and  encourage  the  growth  of  the  new 
hair.  The  following  are  good  lotions: 

3  •    Chloral  hydrat 3  iss. — ii  j. 

Tr.  capsici 3  vj. — xiv. 

Glycerinee 3  i  j- 

Spts.  myrciae q.  s.  ad  §  vi. 

M. 

Instead  of  the  glycerine  and  bay-rum,  oil  of  sweet  almonds  with  co- 


174  THE   VENEREAL   DISEASES. 

logne  water  may  be  preferred,  as  below;  it  is  slightly  more  stimulating, 
and  leaves  the  hair  softer  and  less  sticky. 

$.     Tr.  cantharidis 3  iiss. — iv. 

Ol.  amygdal.  dulcis 3  ij. 

Aquae  cologniensis q.  s.  ad  f  iij. 

M. 

I  have  seen  patients  express  great  satisfaction  with  a  lotion  composed 
of  equal  parts  of  refined  petroleum  and  lime-water,  scented  to  suit. 


SYPHILIS    OF   THE   KAILS. 

The  nails  are  epithelial  appendages  to  the  integument,  very  similar  to 
the  hairs,  and  the  results  of  syphilis  upon  them  is  analogous  to  what  is 
observed  in  the  case  of  the  hair.  If  the  early  eruptions  are  intense  the 
nails  are  apt  to  get  thin,  and  to  lose  their  lustre,  to  show  more  white  dots 
than  usual,  and  to  become  more  brittle  and  liable  to  crack.  Later  in  the 
disease,  when  the  matrix  of  the  nail  is  more  positively  influenced  by  the 
disease,  all  of  these  changes  in  the  nail  may  be  more  marked,  constituting 
a  true  dry  onychia. 

In  onychia  the  nail  first  thins  behind  at  the  lunula.  As  it  grows  for- 
ward, ridges  and  furrows  are  seen  upon  it,  parallel  at  first,  and  then  con- 
verging. The  nail,  in  this  way,  gets  dry,  brittle.  It  looks  dirty  and 
cracks  easily,  and  is  thin,  wavy  and  irregular,  from  lunula  to  tip.  This 
form  of  onychia,  which  Fournier  has  well  described,  is  rare,  but  less  rare 
than  another  form  also  observed  by  Fournier,  in  which,  instead  of  thinning, 
the  nail  ceases  to  grow  entirely,  its  tip  continues  to  grow  forward,  but 
its  posterior  edge  terminates  abruptly  in  a  free,  jagged  margin.  In  this 
manner  the  whole  nail  may  grow  off  and  be  shed.  A  new  nail,  perhaps 
normal,  possibly  distorted  in  various  ways,  ultimately  is  produced  to  take 
the  place  of  the  lost  nail. 

A  more  common  form  of  dry,  syphilitic  onychia,  than  either  of  the 
above,  is  that  in  which  the  nail,  usually  first  at  one  side  of  the  forward 
edge,  becomes  thickened,  friable,  crumbly,  of  a  dirty,  yellowish-white 
color.  The  whole  thickened  surface  of  the  altered  part  of  the  nail  cracks, 
fissures,  and  splits  away  in  pieces,  until  a  portion  of  the  matrix  at  the 
side  has  been  left  dry  and  bare.  Sometimes  a  portion  only  of  the  nail, 
sometimes  the  whole  nail,  is  involved  in  this  process.  The  nail  which  is 
finally  reproduced  is  nearly  always  normal  in  structure  and  appearance. 

All  the  forms  of  onychia  which  have  been  described  are  dry  and  pain- 
less. The  patient  usually  ascribes  them  to  an  injury,  but  they  are  not 
infrequently  symmetrical  on  both  hands.  They  always  get  well  with  or 
without  treatment,  and  their  course  is  invariably  very  slow. 

Treatment. — Internal  mercurial  treatment  certainly  modifies  dry 
onychia  favorably;  but  the  effect  of  treatment  is  very  slow,  owing  to  the 
chronic  nature  of  the  process  and  the  peculiar  structures  involved.  I 
think  I  have  seen  advantage  slowly  fofiow  the  local  use  of  mercurials. 
The  five  or  ten  per  cent,  oleate  of  mercury  (Squibb)  may  be  anointed 
upon  the  dry,  rough  nail  at  night,  and  the  parts  protected  by  a  glove- 
finger.  Fortunately  it  is  uncommon  for  more  than  one  nail  upon  a  hand 
to  be  involved  at  the  same  time,  and  the  patient  usually  manages  to  con- 
ceal the  deformity  until  time  has  relieved  him.  I  do  not  think  that  the 


SYPHILIS   OF   LYMPHATIC    GLANDS,  ETC.  175 

iodides  exercise  so  favorable  an  influence  upon  dry  onychia  as  the  mer- 
curials internally;  but,  as  the  affection  often  comes  on  at  the  end  of  the 
second  year,  or  later,  the  combination  of  some  form  of  iodine  with  the 
mercurial  administered  internally,  is  not  inappropriate. 

Paronychia  due  to  syphilis  is  somewhat  more  common  than  dry 
onychia.  A  mucous  patch  may  appear  under  the  nail,  or  in  the  sulcul 
alongside  of  the  nail,  and,  ulcerating,  involve  the  matrix.  Ulcerative  and 
papulo-squamous  lesions  may  grow  up  to  the  border  of  the  nail,  and  in- 
clude the  matrix  in  a  fissure  or  an  ulcer.  A  papule  on  the  fold  of  skin 
above  the  lunula  leads  to  alteration  in  the  nail.  An  ulcer  preceded  by  a 
small,  painful,  livid  swelling,  may  start  at  one  side  of  the  nail,  and  run 
around  the  border,  involving  the  nail,  and  causing  it  to  be  shed  by  sup- 
puration of  the  matrix.  Such  ulcers  are  apt  to  be  attended  by  the  for- 
mation of  exuberant  granulations  at  the  borders  of  the  undermined  nail. 
The  secretions  are  retained  in  such  cases  long  enough  to  putrefy  in  part, 
and  they  become  thin  and  offensive  in  odor.  The  whole  or  only  a  por- 
tion of  the  nail  may  come  away,  and  the  ulcer  which  takes  its  place  may 
eat  down  into  the  matrix  deeply  enough  to  destroy  it.  The  whole  toe  or 
finger  may  inflame  (dactylitis),  and  the  ungual  phalanx  may  be  involved 
in  necrosis.  When  the  ulcer  is  deep  enough  to  involve  the  matrix  to  a 
considerable  extent,  a  healthy  nail  is  not  again  produced,  but,  after  heal- 
ing, which  always  takes  place,  the  nail  may  be  represented  by  a  deformed 
substitute,  or  by  uneven  bands  of  cicatricial  tissue  containing  varied 
amounts  of  nail-substance.  A  gummy  tumor  commencing  in  the  matrix, 
(usually  near  the  lunula),  sometimes  occurs,  terminating  in  ulceration, 
sweeping  away  the  nail,  and  threatening  the  whole  phalanx. 

The  diagnosis  of  syphilitic  onychia  and  paronychia  is  difficult.  The 
dry  onychia  in  its  different  forms  is,  in  many  cases,  difficult  to  distinguish 
from  similar  conditions  produced  by  eczema  and  psoriasis.  The  ulcera- 
tive  form  resembles  ingrowing  nail,  but  in  the  syphilitic  disease  the  matrix 
is  usually  involved  first,  and  not  secondarily,  as  in  ordinary  ingrowing 
nail,  or  in  common  runround.  The  gummy  tumor  is  not  apt  to  be  taken 
for  anything  else. 

The  treatment  of  paronychia,  and  of  ulcerated  matrix  generally,  is 
to  keep  the  parts  scrupulously  clean  by  washing  with  warm  water  and 
soap,  by  means  of  a  camel's  hair  brush;  to  remove  all  dead  and  raised 
portions  of  nail  (often,  with  advantage,  the  whole  nail),  and  to  treat  the 
stage  of  syphilis  in  which  the  malady  occurs  with  the  remedies  appropri- 
ate to  that  stage.  The  best  local  applications  for  the  ulcers  are  pure 
iodoform  freely  used,  black  and  yellow  wash,  mild  oleate  of  mercury,  and 
the  judicious  use  of  poulticing,  pressure,  and  nitrate  of  silver  if  the  granu- 
lations are  exuberant. 


DACTYLITIS. SYPHILIS    OF   THE    FINGERS    AND    TOES. 

This  is  an  important  form  of  syphilis.  It  falls  naturally  into  place 
here,  since  many  tissues  are  involved  at  the  same  time  in  the  affection,  and 
the  malady  cannot  well  be  described  under  the  head  of  any  of  them  alone. 
Syphilitic  dactylitis  did  not  receive  much  attention  until  a  few  years 
since,  but  now  enough  cases  have  been  minutely  recorded  to  make  its  his- 
tory a  clear  one.  It  occurs  in  two  forms:  the  one  involving  the  joint 
and  more  superficial  tissues,  the  other  the  bone  and  joint.  Both  are 
gummatous. 


176  THE   VEITEKEAL   DISEASES. 

The  first  form  is  a  gummy  infiltration  of  the  periosteum  and  subcuta- 
neous tissues.  But  one  phalanx  (generally  the  proximal)  may  be  involved, 
or  the  whole  finger  may  share  in  the  morbid  process.  I  am  now  treating 
a  case  of  six  months'  duration,  in  which  the  disease  commenced  as  a  tuber- 
culo-squamous  eruption  upon  the  thenar  eminence.  The  thumb  became 
involved  in  a  spread  of  the  eruption,  and  then  suddenly  all  of  its  tissues 
became  infiltrated  in  almost  a  painless  way,  until  the  thumb  was  more  than 
twice  the  size  of  its  fellow,  and  much  crippled  as  to  the  movements  of  its 
joints.  The  eruption,  meantime,  continued  upon  the  thumb,  and  remained 
there  after  the  latter  had  been  reduced  by  treatment  very  nearly  to  the 
size  of  the  thumb  of  the  other  hand. 

The  swelling  in  this  form  of  dactylitis  is  firm,  ends  abruptly,  and  does 
not  shade  off  into  the  surrounding  skin.  It  is  not  attended  by  pain  ex- 
cept on  motion,  which  is  generally  mechanically  interfered  with  by  the 
swelling.  The  color  of  the  integument  is  often  a  livid,  light  red,  whether 
there  is  any  eruption  upon  the  skin  or  not.  If  the  disease  is  allowed  to 
progress,  the  ligaments  of  the  joint  next  become  involved.  Effusion  into 
the  joint  is  exceptional  in  this  form  of  disease.  Finally,  the  cartilages 
erode  and  the  joint  is  destroyed,  the  bones  becoming  implicated  at  this 
time. 

The  course  of  the  affection  is  slow,  and  relapse  not  uncommon.      Per- 


FIG.  17.    Dactylitis  of  the  toe. 

sistent  treatment  is  always  curative,  but,  if  the  cartilages  have  been  in- 
volved or  the  joint  disintegrated,  loss  of  function  necessarily  follows. 

Fig.  17,  after  Taylor,  represents  a  toe  which  is  the  seat  of  this  dif- 
fuse dactylitis. 

The  other  form  of  dactylitis  is  a  gummy  tumor  of  the  bone,  starting 
sometimes  under  the  periosteum,  sometimes  in  the  medullary  membrane. 
One  or  more  phalanges  may  be  attacked.  Fig.  18,  after  Berg,  repre- 
sents the  common  seat  of  the  tumor  in  a  typical  case,  the  proximal  pha- 
lanx. Effusion  may  take  place  into  a  joint,  and  the  latter  may  be  in- 
volved in  the  disease  even  to  a  greater  extent  than  the  intervening  pha- 
lanx. I  had  one  such  case  at  the  Charity  Hospital,  in  which  the  meta- 
carpo-phalangeal  joint  of  the  thumb  and  of  the  great  toe  on  the  right 
side  bore  the  whole  brunt  of  the  disease. 

The  superficial  and  surrounding  tissues  often  escape  implication  in  an 
extraordinary  way.  The  skin  may  be  of  a  livid  pink  from  tension,  but 


SYPHILIS    OF    LYMPHATIC    GLANDS,  ETC. 


177 


not  at  all  structurally  altered;  the  nail  generally  escapes,  even  when  the 
ungual  phalanx  is  the  seat  of  disease. 

The  natural  evolution  of  this  malady  seems  to  be  that  it  culminates 
after  a  time,  and  the  gummy  tissue,  not  being  organized,  is  reabsorbed 
without  breaking  down.  Very  rarely  does  the  gummy  tissue  disintegrate 
and  ulcerate  its  way  to  the  surface.  As  a  result  of  this  interstitial  ab- 


FIG.  18.     Berg's  finger. 


sorption,  the  bone  atrophies  visibly  and  the  phalanx  shortens.  When 
two  bones  and  an  intervening  joint  have  been  involved,  the  shortening 
due  to  absorption  is  so  considerable  as  to  reduce  the  whole  finger  greatly 
in  length.  In  a  case  of  McCready's,  which  he  kindly  showed  to  me  and 
which  has  been  pictured  by  Taylor  *  (Fig.  19),  the  deformity  produced  by 


FIG.  19. 


this  absorption  was  very  striking.  There  had  been  noulceration  reaching 
the  surface  in  this  case,  and  the  functions  of  the  fingers  were  compara- 
tively good. 

When  the  centre  of  a  phalanx  only  is  involved  in  the  disease,  absorp- 
tion of  the  gummy  material  may  leave  the  bone  separated  in  its  centre. 


'  Am.  Journal  of  Dermatology  and  Syphilography,  January,  1871. 
12 


178  THE    VENEREAL    DISEASES. 

In  such  a  case  the  two  ends  generally  come  together  as  a  false  joint,  and 
the  skin  over  them  contracts,  so  as  to  conform  itself  to  the  new  order  of 
things.  There  is  no  pain  at  all,  as  a  rule,  in  this  form  of  dactylitis. 

The  diagnosis  in  dactylitis  is  very  easy.  The  first  diffuse  variety 
can  hardly  be  mistaken  for  any  other  malady.  Gout  and  all  ordinary  in- 
flammations are  too  painful  to  be  confounded  with  it.  The  second  form 
might  be  mistaken  for  enchondroma,  which  also  is  painless,  and  apt  to 
appear  upon  the  phalanges.  Enchondroma  grows  more  slowly,  and  pre- 
fers the  palmar  aspect  of  the  bone  as  a  point  of  origin,  while  dactylitis 
starts  more  often  upon  the  dorsum  of  a  bone  (in  the  periosteal  form). 
A  close  study  of  the  course  of  the  affection  will  clear  up  the  diagnosis. 

Prognosis. — Syphilitic  dactylitis,  even  if  left  to  itself,  always  gets 
well;  but  it  is  apt  to  do  so  at  the  expense  of  deformity  and  more  or  less 
interference  with  function.  Its  progress  may  be  arrested  at  almost  any 
stage  by  a  bold  and  efficient  treatment. 

Treatment. — The  diffuse  form  requires  mercury  in  combination  with 
iodide  of  potassium  or  some  other  iodide,  which  (the  iodide)  must  be  un- 
sparingly pushed  as  rapidly  as  the  stomach  will  allow.  The  second  form 
needs  no  mercury,  but,  like  all  pure  gummata,  yields  generally  a  very 
ready  response  to  the  vigorous  use  of  the  iodides.  They  should  be  com- 
bined with  a  vegetable  bitter,  and  given  lavishly.  In  the  way  of  local 
treatment,  inunctions  of  mercurial  ointment,  or  of  the  oleates,  seems  to 
help  along,  and  I  have  thought  that  pressure  was  sometimes  of  service. 
The  effect  of  treatment  in  any  case  is  slow. 


SYPHILIS   OF    THE    MUSCLES. 

Syphilis  attacks  the  muscles  by  involving  their  connective-tissue  at- 
mosphere in  congestive  and  hyperplastic'  processes,  or  by  the  formation, 
in  this  atmosphere,  of  gummatous  deposit.  The  contractile  function  of 
the  muscle  is  always  interfered  with  while  under  the  influence  of  the  at- 
tack. The  diffuse  hyperplastic  form  tends  to  produce  cirrhosis  of  the 
muscle  and  atrophy;  the  gumma  destroys  the  part  of  the  muscle  it  occu- 
pies. 

There  are  three  forms  of  syphilis  of  the  muscle:  the  congestive,  the 
diffuse  hyperplastic,  the  gumma. 

The '  congestive  myositis  may  be,  and  doubtless  is  a  mild  degree 
of  the  diffuse  hyperplastic  form.  Notta '  first  called  attention  to  it  as  a 
peculiar  affection  of  the  biceps,  and  Mauriac J  recently  has  collected 
eighteen  cases  (nine  of  them  personal),  out  of  which  he  constructs  a  new 
subdivision  of  syphilitic  myositis. 

The  malady  in  question  appears  to  involve  mainly  the  lower  end  of 
the  biceps  cubiti.  Other  muscles  also  suffer — notably,  the  triceps  in  the 
arm.  The  malady  comes  on  between  the  sixth  and  the  tenth  months, 
oftener  in  light  than  in  severe  syphilis,  and  usually  in  patients  who  have 
suffered  from  pains  in  the  muscles  and  fibrous  tissues  previously  in  the 
disease.  Mauriac  observed  it  more  often  on  the  left  side,  and  accompany- 
ing dry  rather  than  moist  cutaneous  lesions.  Usually  the  affection  is 
unilateral,  or,  if  bilateral,  of  unequal  intensity  on  the  two  sides. 

It    comes  on    insidiously,  and  advances  slowly.     In  the  biceps  —  its 


1  Archiv.  g^n.,  1850,  p.  413. 

•  LeconH  sur  lea  myopathies  syphilitiqnee.     Paris.  Delahaye,  1878.  pp. 


208. 


SYPHILIS    OP   LYMPHATIC    GLANDS,  ETC.  179 

muscle  of  election — the  malady  shows  itself  by  an  inability  to  straighten 
the  arm  completely,  on  account  of  the  pain  caused  by  the  effort  at  the 
lower  point  of  attachment  of  the  muscle.  Flexion  is  normal.  When  the 
triceps  brachialis  is  simultaneously  involved,  the  elbow  becomes  fixed 
(muscular  anchylosis). 

In  this  affection,  according  to  Mauriac,  all  the  tissues  about  the  joint 
are  normal,  except  the  tendon  of  the  biceps,  which  is  short,  hard,  stiff, 
prominent.  The  muscular  fibres  appear  to  be  semi-contracted — a  condi- 
tion increased  by  forced  extension  or  voluntary  flexion.  Occasionally, 
there  are  dull  pains  in  the  muscle  by  night.  The  pain  on  forced  exten- 
sion is  referred  to  the  upper,  inner  part  of  the  lower  tendon  of  the  biceps. 
If  the  triceps  is  also  involved,  there  is  another  focus  of  tenderness  above 
the  olecranon.  These  points  are  generally  sensitive  to  pressure. 

Untreated,  this  affection  continues  for  several  months — occasionally, 
several  years — but  always  gets  well  eventually,  without  altering  the  mus- 
cular structure.  Mauriac  believes  the  lesion  to  be  hypersemia. 

The  diffuse  form  of  connective-tissue  hyperplasia  is  a  chronic  myo- 
sitis  of  specific  nature.  The  parenchyma  of  the  muscle  becomes  thick- 
ened by  the  development  of  new  round  and  fusiform  cells,  which  go  on 
to  organization  into  fibres,  lose  their  succulent  character,  contract  like 
cicatricial  tissue  (as  in  cirrhosis)  upon  the  muscular  elements,  and,  un- 
treated, in  the  end  lead  to  atrophy  of  the  muscle,  with  more  or  less  short- 
ening and  loss  of  function. 

In  this  affection  there  is  no  pain,  but  the  muscle  gradually  shortens, 
diminishes  in  size,  and  becomes  more  fibrous  in  texture.  Muscles  of  the 
upper  extremity  (particularly  the  flexors)  and  of  the  face  are  more  often 
involved  than  those  of  the  lower  extremity. 

Treatment  is  of  advantage  in  some  cases,  even  after  atrophy  has  com- 
menced. All  cases  treated  early  are  favorably  influenced  by  a  combina- 
tion of  mercury  with  the  iodides. 


GUMMA    OF   THE    MUSCLE. 

A  gummy  tumor  may  form  in  any  muscle  among  the  connective-tissue 
elements,  or  in  the  sheath.  A  gumma  here  is,  as  it  is  elsewhere,  at  first  a 
collection  of  nucleated,  round  and  spindle  cells,  which  finally  become  ab- 
sorbed, or  remain  as  a  mass  of  cheesy  debris,  or  soften  and  find  their  way 
to  the  surface,  acting  just  as  gumma  does  when  its  seat  is  in  the  subcu- 
taneous connective  tissue. 

No  muscle  is  exempt  from  liability  to  attack,  but  certain  large  muscles, 
gluteus,  pectoralis  major,  sterno-cleido-mastoid,  trapezius,  the  heart,  are 
most  commonly  the  seat  of  the  new  growth,  or  certain  delicate  muscles, 
those  of  the  tongue,  larynx,  pharynx,  soft  palate. 

The  symptoms  of  gumma  of  a  muscle  are  at  first  only  a  tumor  in  the 
muscle,  which  is  painless,  and  often  of  considerable  size  when  first  dis- 
covered. In  a  large  muscle  the  tumor  is  found  to  be  stationary,  when  the 
muscle  is  thrown  into  contraction;  at  other  times  movable  (Nelaton).  The 
skin  is  normal  over  the  tumor  until  the  latter  approaches  the  surface  and 
begins  to  soften,  and  then  there  may  be  complaint  of  some  pain,  especially 
at  night. 

The  termination  of  gumma  is  in  destruction  of  all  the  muscular  fibre 
involved  in  the  new  growth,  whether  the  gumma  becomes  cheesy,  or  soft- 


180  THE    VENEREAL    DISEASES. 

ens  and  discharges.  Prompt  treatment  alone  can  arrest  destruction  of 
tissue. 

The  symptoms  of  gummata  of  the  pharynx,  larynx,  and  tongue  are  de- 
tailed elsewhere. 

The  diagnosis  of  a  muscular  gumma  is  only  possible,  in  many  instan- 
ces, by  aid  of  the  history  and  concomitant  symptoms,  and  by  the  effect  of 
treatment. 

Treatment  with  iodides  in  large  doses  is  generally  promptly  effective 
of  a  cure  in  the  earlier  stages  of  gumma.  After  the  mass  has  softened, 
treatment  is  sometimes  incapable  of  preventing  perforation  of  the  skin 
and  discharge  of  the  syrupy  and  cheesy  debris. 


SYPHILIS  OF  TENDONS,  SHEATHS  OP  TENDONS  AND  APONEUROSES. 

Verneuil  first,  and  later  Fournier,  have  described  affections  of  the 
sheaths  of  tendons  due  to  syphilis.  The  sheaths  of  the  tendons  on  the 
back  of  the  wrist  in  secondary  syphilis  may  become  the  seat  of  effusion, 
swelling  up  in  triangular  form,  with  the  base  toward  the  fingers,  or  the 
effusion  may  be  less  generalized.  The  swelling  fluctuates,  and  usually  is 
unattended  by  pain.  Occasionally,  however  (Fournier),  pain,  heat,  red- 
ness, and  interference  with  function,  are  as  great  as  in  inflammatory  ten- 
osynitis. 

Other  tendons  about  other  joints  may  be  involved  in  a  similar  process, 
but  the  affection  at  best  is  a  rare  one,  and  the  back  of  the  wrist  its  point 
of  election. 

Treatment  is  mercury  internally,  and  it  is  usually  promptly  effective. 

Tendons  are  sometimes  involved  in  syphilitic  diffuse  interstitial  con- 
nective-tissue thickening,  and  extensive  gummata  of  nearly  all  the  large 
tendons  have  been  placed  on  record.  Gummata  of  tendons  are  painless 
until  they  create  irritation  by  their  size,  or  by  commencing  to  soften. 
When  they  become  painful,  the  muscle  from  which  they  spring  generally 
refuses  to  act. 

The  aponeuroses  are  subject  to  the  same  changes  as  the  tendons. 

Treatment  is  that  of  tertiary  syphilis  :  mixed  treatment  for  the  dif- 
fused form  of  disease;  iodides  alone  for  gummata. 


SYPHILIS    OF   THE    BUKS^B. 

Verneuil  has  reported  an  interesting  observation  of  simple  dropsy  of 
the  bursa  behind  the  olecranon,  without  thickening  of  the  walls  of  the 
bursa,  and  due  to  secondary  syphilis.  Verneuil  and  Moreau  have  given 
cases  of  tertiary  syphilitic  affections  of  the  bursje.  I  have  reported ' 
several  cases  of  tertiary  syphilitic  bursitis,  and  observed  a  number  of 
others  since  the  publication  of  my  paper  upon  the  subject. 

Tertiary  syphilitic  housemaid's  knee  is  the  most  common  apparently 
of  all  forms  of  syphilitic  bursitis.  Next  in  liability  to  attack  seems  to  be 
the  bursa  at  the  inner  side  of  the  knee.  The  bursa  behind  the  olecranon 
follows.  The  other  bursae  are  attacked  on  the  whole  very  seldom.  The 
malady  is  far  from  common  in  any  of  its  forms. 

Figs.  20  and  21  represent  two  cases  of  tertiary  syphilitic  housemaid's 

1  Syphilis  <u»  affecting  the  Burae :  Am.  Jour,  of  Med.  Sci. ,  April,  1876,  p.  349. 


SYPHILIS    OF    LYMPHATIC    GLANDS,  ETC. 


181 


knee  taken  from  my  paper  upon  the  subject.  Fig.  20  shows  the  first 
form  of  the  affection,  that  commencing  from  without.  A  deep  tuber- 
culo-squamous,  perhaps  ulcerative,  syphilide  appears  first  over  the  knee 
and  involves  the  integument  covering  the  bursa.  The  skin  thickens, 
is  livid,  rough  on  the  surface,  perhaps  ul- 
cerated. It  becomes  sometimes  almost 
elephantiasic  in  thickness,  and  shows  deep 
lateral  burrows  due  to  the  motions  of  the 
joint,  but  the  physical  characters  of  the 
eruptions  and  ulcers  upon  the  surface  mark 
the  process  as  syphilitic. 

After  the  morbid  changes  have  reached 
this  height,  and  sometimes  long  before  it, 
when  there  is  only  an  eruption  lying  over 
the  bursa  in  front  of  the  patella,  the  tissues 
surrounding  the  latter  become  involved  in 
the  disease.  The  walls  of  the  bursa  some- 
times thicken  enormously  and  a  gummatous 
infiltration  invades  its  whole  structure  and 
grows  into  its  cavity.  The  tendency  of  this 
newly  formed  tissue  is  to  become  soft,  gela- 
tinous, and  to  work  its  way  by  ulceration 
to  the  surface,  where  it  discharges  as  a 
puriform  material  containing  the  debris  of 
the  bursa.  In  this  way  the  morbid  material 
eliminates  itself,  and  cicatrization  effects  a 
cure,  although  fistula  may  remain  leading 
through  the  skin  to  the  site  of  the  former 
bursa  for  a  considerable  period. 

The  second  form,  Fig.  21,  commences  from  within.  It  is  an  infiltra- 
tion of  the  bursa,  with  gummy  material,  primarily,  the  surrounding  tissues 
and  the  skin  being  spared  until  the  tumor  formed  by  the  bursa  has  soft- 
tened,  contracted  adhesions,  and  prepared  to  discharge  externally.  The 
affection  comes  on  insidiously,  is  often  discovered 
by  accident,  is  absolutely  painless  until  softening 
sets  in. 

The  diagnosis  of  the  first  described  form 
of  syphilitic  housemaid's  knee  is  easy  on  account 
of  the  accompanying  eruptive  phenomena  upon 
the  integument  over  the  knee.  In  the  second 
form  diagnosis  is  almost  impossible  except  from 
the  history.  The  tumor  may  be  symmetrical,  but 
if  so,  is  usually  uneven  on  the  two  sides;  the 
bursa  is  as  hard  as  a  nut  at  first  and  throughout, 
until  the  gumma  begins  to  break  up  and  the  skin 
to  adhere.  Only  occasionally  can  any  fluctuation 
be  felt  before  this  time.  These  features  may 
distinguish  some  cases  from  common  housemaid's 
knee,  but  certain  indolent  forms  of  the  latter 
resemble  it  greatly,  even  in  the  peculiar  woody 
hardness  which  the  syphilitic  variety  always  possesses  in  a  high  degree. 

For  the  other  bursae,  when  implicated  in  syphilitic  disease,  concomi- 
tant symptoms,  study  of  the  case  and  of  the  history,  must  be  depended 
upon  to  clear  up  the  diagnosis. 


FIG.  20. 


FIG.  21. 


182  THE    VENEREAL    DISEASES. 

The  course  of  tertiary  syphilitic  bursitis  is  very  protracted;  months  or 
years  may  be  involved  in  the  evolution  of  the  disease,  and  a  syphilitic 
ulcer  or  sinuses  may  persist  almost  indefinitely  after  the  bursa  has  soft- 
ened and  discharged  externally. 

Treatment  should  be  mixed.  The  iodides  are  more  powerful  in  dis- 
persing the  tumor  than  mercurials,  but  the  effect  of  treatment  is  not 
promptly  observed,  and  the  combination  of  mercury  with  the  large  doses 
of  the  iodides  seems  to  increase  the  effect  of  the  latter.  The  free  local 
use  of  the  oleate  of  mercury  at  five  or  twenty  per  cent,  strength,  accord- 
ing to  its  effect  upon  the  skin,  has  certainly  a  positive  value.  Treat- 
ment is  of  advantage  in  shortening  the  duration  of  the  affection  in  all  its 
stages,  the  ulcerative  as  well  as  the  others;  but  it  is  very  desirable  to  bring 
treatment  to  bear  upon  the  tumor  before  the  skin  has  become  involved, 
since  in  this  manner  absorption  of  the  gumma  can  generally  be  effected, 
and  prolonged  suppuration  as  well  as  the  subsequent  scarring  may  be 
avoided. 


SYPHILIS   OF   LIGAMENTS   AND   JOINTS. 

The  joints  are  involved  occasionally,  both  in  secondary  and  in  tertiary 
syphilis.  The  joint  affection  in  the  former  case  is  attended  by  pain,  spon- 
taneous and  on  pressure,  and  by  fever,  which  may  run  to  such  a  height 
as  to  make  the  malady  assume  the  form  of  acute  articular  rheumatism, 
especially  as  sweating  is  apt  to  be  a  feature  of  the  malady,  with  acid  urine 
full  of  urates;  this  of  course  in  severe  cases.  The  pains  felt  so  commonly 
in  the  joints  during  secondary  syphilis  are  not  necessarily  located  in  the 
joint  itself.  They  may  be  due  to  changes  in  the  bursae,  in  the  tendons,  in 
the  periosteum  about  the  joint.  When  the  joints  are  involved  in  early 
syphilis,  there  is  generally  some  effusion  of  fluid.  The  affection  always 
gets  well  and  yields  to  mercury. 

The  acute  form  may  also  occur,  according  to  Duffin,'  Biiumler,*  late  in 
syphilis.  Its  diagnosis  (Duffin)  is  always  easy,  since  the  fever  accompany- 
ing it  is  decidedly  intermittent,  with  nocturnal  exacerbations,  and  this 
fever  as  well  as  the  rheumatism  yields  a  quick  response  to  antisyphilitic 
treatment. 

A  chronic  hydarthrosis,  due  to  tertiary  syphilis,  without  any  thicken- 
ing of  the  structures  forming  the  joint,  is  occasionally  encountered.  I 
have  seen  two  such  cases.  Both  of  them  yielded  very  promptly  to  the 
iodide  of  potassium. 

Gummatous  infiltration  of  the  small  joints,  terminating  in  their  disin- 
tegration and  destruction,  sometimes  with  opening  and  discharge  exter- 
nally, sometimes  without  it,  has  been  referred  to  in  connection  with  dac- 
tylitis. 

The  larger  joints  also  suffer  in  tertiary  syphilis,  their  ligaments,  capsule, 
and  the  surrounding  tissues  becoming  the  seat  of  gummatous  infiltration. 
A  number  of  cases  have  been  reported  in  which  various  joints  have  been 
involved. 

The  knee  suffers  far  more  frequently  than  any  other  joint.  A  gummy 
deposit  takes  place  in  the  capsule,  in  a  diffused  form,  with  localized  areas 
of  greater  thickening — the  extra  deposits  being  often  in  the  loose  portion 

1  Trans,  din.  Soc.  of  London,  Vol.  II.,  1869,  p.  81. 

*  Ziemasen's  Cyclopedia  (Am.  Translation),  Vol.  III.,  p.  177. 


SYPHILIS    OF    LYMPHATIC    GLANDS,  ETC.  183 

of  the  capsule,  extending  above  the  knee  in  front  under  the  tendon  of  the 
quadriceps  muscle.  Together  with  this  thickening  of  the  capsule,  there 
occurs  slowly  an  inconsiderable  effusion  into  the  joint.  This  effusion 
may  be  absorbed  and  form  again — a  feature,  according  to  Richet,  of  diag- 
nostic value  for  the  syphilitic  form  of  synovitis.  There  is  no  pain  early 
in  the  disease,  and  no  fever.  The  joint  feels  weak,  but  motion  at  first  is 
not  painful,  only  the  joint  gets  tired  sooner  than  its  fellow. 

The  malady  is  usually  unilateral.  As  the  changes  progress,  nocturnal 
pains  often  set  in,  the  joint  assumes  more  or  less  of  a  fusiform  shape,  re- 
calling white  swelling,  with  which  it  is  ordinarily  confounded.  The  knee 
becomes  distinctly  hot  to  the  hand. 

Finally  the  cartilages  soften  and  disintegrate,  gummatous  material 
fills  the  cavity  of  the  joint.  Softening  of  the  gumma  takes  place  with 
discharge  externally,  or  even,  in  the  case  of  absorption,  the  joint  has  be- 
come disorganized,  its  functions  forfeited,  and  anchylosis  ensues. 

The  diagnosis  of  syphilitic  arthropathy  of  the  knee  is  with  white 
swelling.  In  white  swelling  (strumous  fungous  arthritis)  the  patient  is 
generally  young,  the  joint  becomes  hot  and  painful  early  in  the  disease, 
and  uniformly  involved  in  the  general  oval  thickening  of  the  tissues  from 
the  first.  There  is  not  so  insidious  an  onset  as  in  syphilis,  and  no  local- 
ized hard  bodies  in  the  loose  capsule  above  the  joint,  in  the  beginning, 
suggestive  of  loose  cartilages  in  the  joint.  The  peculiar  indolence  of  the 
syphilitic  arthropathy  is  its  chief  diagnostic  feature — an  indolence  which 
allows  painless  motion  to  the  joint  many  months  after  all  motion  would 
have  ceased  had  the  disease  been  due  to  another  cause.  I  have  seen  a 
number  of  cases  of  syphilitic  arthropathy  of  the  knee,  among  them  one 
had  been  long  treated  as  a  white  swelling,  another  as  rheumatism,  another 
was  amputated,  another  ignored.  Unfortunately,  syphilis  as  affecting  the 
joints  is  not  sufficiently  well  known  among  the  profession  to  be  carefully 
looked  for,  and  many  cases  go  badly  by  default. 

Treatment. — Mixed  treatment,  with  the  iodides  in  excess,  yields  won- 
derful results  in  this  malady.  Few  cases  are  so  bad  that  they  cannot  be 
benefited,  and  in  almost  any  case  where  the  cartilages  have  not  been 
eroded,  no  matter  for  how  many  months  the  affection  of  the  joint  has 
lasted,  a  cure  may  be  pretty  confidently  expected  by  an  active  treatment 
pushed  rapidly  at  first,  and  prolonged  in  a  milder  form  for  a  considerable 
period  after  apparent  recovery.  The  local  use  of  mercurial  plasters  and  of 
the  oleate,  and  the  employment  of  pressure  locally  assist  in  the  rapidity 
of  the  cure.  All  things  considered,  treatment  may  be  expected  to  act  with 
considerable  promptness  in  these  cases.  After  disintegration  of  the  joint, 
or  anchylosis,  the  effect  of  treatment  can  do  no  more  than  arrest  the  dis- 
ease. It  cannot  cause  the  formation  of  a  perfect  joint. 

Effusion  into  a  joint  may  take  place  in  connection  with  syphilitic  dis- 
ease of  one  of  the  bones  entering  into  its  structure,  and  that  without  any 
physical  lesion  of  the  joint,  except  hyperaemia.  Such  symptoms  depend- 
ent upon  disease  of  the  bone  yield  when  the  latter  gets  well. 

SYPHILIS    OF   THE    BONES. 

The  bones  may  be  involved  in  secondary,  as  well  as  in  late  syphilis. 
The  epiphyseal  changes  in  the  long  bones  will  be  noticed  under  the  head 
of  inherited  syphilis.  Mauriac  '  has  observed  nodes  in  secondary  syphilis 

1  Affections  syphilitiques  precoces  du  systeme  osseux.     Paris,  1872. 


184  THE   VENEREAL    DISEASES. 

upon  a  number  of  different  bones,  and  other  investigators  have  reported  a 
few  cases.  These  nodes,  however,  are  not  the  destructive  gummata  of  late 
syphilis  ;  indeed,  rather  rarely  do  they  even  go  on  to  organization  and  hy- 
perostosis,  the  common  termination  of  ordinary  nodes  in  tertiary  disease. 
The  secondary  syphilitic  node  is  often  only  a  subperiosteal  oedema  and  hy- 
persemia  coming  on  suddenly,  perhaps  as  the  result  of  local  injury,  disap- 
pearing promptly  under  treatment,  and  leaving  behind  no  trace  of  its  ex- 
istence. 

Some  few  of  the  secondary  subperiosteal  swellings,  however,  do  lead 
to  local  thickening  of  bone,  which  remains  permanent. 


OSTEOCOPIC    PAINS 

commonly  occur  in  secondary  syphilis,  and  often  in  late  syphilis  as  well. 
They  are  pains  of  a  splitting,  boring,  bone-breaking  character,  coming  on 
at  night  in  certain  bones,  sometimes  with  great  regularity  and  terrible 
fierceness,  and  ceasing  toward  morning.  These  pains  are  probably  due 
to  slight  periosteal  swellings  in  secondary  syphilis,  attended  by  considera- 
ble subperiosteal  hyperaemia.  Ordinarily  tolerable,  they  are  sometimes  ex- 
cruciatingly painful  in  character.  The  warmth  of  the  bed  seems  to  inten- 
sify them  (Ricord),  and  sometimes  the  weight  of  the  bed-clothes  cannot  be 
borne  upon  a  bone  which  is  the  seat  of  pain.  Baiimler  thinks  that  it  is 
not  the  heat  of  the  bed,  or  the  night  time,  which  causes  the  pain,  but  a 
febrile  exacerbation  coming  on  toward  evening,  which  dilates  the  periph- 
eral blood-vessels.  Occasionally,  but  very  rarely,  the  pains  come  on  by 
day,  and  cease  by  night.  In  such  cases  no  thermometric  observations 
have  been  made,  so  far  as  I  am  aware. 

These  osteocopic  pains  are  often  relieved  somewhat  by  pressure.  They 
occur  about  the  head  and  neck,  the  shoulders,  elbows,  and  knees,  and  in 
the  continuity  of  the  long  bones.  The  previous  use  of  mercury  has  noth- 
ing whatsoever  to  do  with  the  causation  of  these  pains,  which,  on  the  con- 
trary, are  not  apt  to  come  at  all  if  mercury  has  been  commenced  early 
enough,  and  which  disappear  more  quickly  under  the  use  of  mercury 
than  under  the  employment  of  any  other  drug. 

In  connection  with  the  pains,  sometimes,  when  the  bone  is  superficial 
(cranium,  tibia),  the  periosteum  is  apparently  raised  a  little,  and  gives  to 
the  fingers  an  obscure  sense  of  fluctuation.  Often,  on  the  other  hand,  in 
early  syphilis,  the  osteocopic  pains  lie  at  the  attachment  of  the  tendons 
of  muscles  into  the  articular  ends  of  bones. 

The  night  headache  of  early  syphilis  is  usually  an  intense  osteocopic 
pain. 

Treatment. — Osteocopic  pains  early  in  syphilis  are  favorably  influ- 
enced by  both  mercury  and  the  iodides,  but  mercury  has  decidedly  the 
more  power  over  them.  When  the  pains  are  only  moderate,  they  do  not 
call  for  any  deviation  in  the  general  treatment  which  the  stage  of  the 
disease  calls  for  in  which  they  occur.  When  they  are  intense,  however, 
mercury  in  minute  doses,  frequently  repeated,  will  sometimes  relieve  them 
very  promptly.  This  is  known  as  Trousseau's  plan  of  treating  early 
syphilitic  headache.  It  is  often  of  value  in  the  treatment  of  other  in- 
tense osteocopic  pains.  From  one-fifteenth  to  one-tenth  of  a  grain  of 
calomel  may  be  given  in  this  treatment  hourly,  for  twenty-four  hours. 
Then  it  is  well  to  arrest  treatment  for  one  day,  and  then  repeat  a  similar 
course.  The  object  of  interupting  treatment  is  the  fear  of  salivation  or 


SYPHILIS    OF    LYMPHATIC    GLANDS,  ETC.  185 

of  intestinal  disturbance,  of  which  there  is  some  danger  when  this  method 
is  pushed  in  susceptible  cases. 

When  osteocopic  pains  come  on  in  late  syphilis,  they  generally  indi- 
cate a  tendency  to  serious  disease  of  bone,  and  call  for  the  iodides  in 
large  doses.  The  mercurials  are  also  of  advantage  here,  but  the  iodides 
outrank  them. 

Of  the  serious  lesions  of  bone  produced  by  syphilis,  three  require  de- 
scription :  the  node,  dry  caries,  and  the  gummy  tumor. 


THE    NODE. 

A  node  is  an  inflammatory  osteo-periostitis,  terminating  generally  in 
new  formation  of  bone.  The  subperiosteal  tissues  first  become  con- 
gested, then  there  is  a  new  formation  of  soft,  round,  and  spindle  cells. 
By  this  proliferative  cell-formation,  the  periosteum  is  raised  over  a  vari- 
able area  in  the  form  of  a  rounded  lump,  which  gradually  shades  off  into 
the  surrounding  tissues.  This  lump  is  soft,  and  at  first  quite  painful, 
•especially  upon  pressure.  Manipulation  proves  it  to  be  attached  to  the 
bone.  The  skin  over  it  is  freely  movable,  and  not  discolored.  There  is 
often  oadema,  especially  in  young  nodes  of  large  size.  The  pain  in  these 
nodes  is  sometimes  considerable,  spontaneously,  especially  if  they  are 
situated  on  the  shin,  and  if  the  patient  walks  or  stands  much.  The  pain 
is  quite  certain  to  be  intensified  at  night. 

The  bones  most  often  involved  are  the  flat  bones  (cranium)  and 
superficial  bones  (tibia,  clavicle,  ulna).  Local  injury,  a  blow,  will  some- 
times cause  a  node  to  appear,  but  neither  situation  nor  local  violence  is 
necessary  for  their  production,  for  they  sometimes  grow  from  the  inner 
table  of  the  skull,  where  they  cause  great  damage  by  pressure,  and  they 
are  occasionally  found  upon  a  deep-seated  bone  (femur,  vertebral  column) 
well  down  among  the  muscles. 

The  date  of  appearance  of  nodes  is  late  in  syphilis.  Early  forms  do 
occur,  as  already  mentioned;  but  they  are  not  important,  and  generally 
disperse,  leaving  no  trace. 

The  course  of  a  node  is  generally  slow.  •  After  remaining  soft  for  a 
varying  period,  they  become  firmer,  and  gradually  disappear  by  absorp- 
tion under  treatment  or  (sometimes)  spontaneously,  leaving  no  trace 
behind,  or  only  a  depression  surrounded  by  a  hard  border  of  new  bone, 
which  has  formed  at  the  circumference,  while  no  bone-salts  have  been  de- 
posited centrally.  Occasionally  a  node  softens  centrally,  the  skin  over 
it  beoomes  involved,  red,  adherent.  The  softened  node  discharges  and  a 
syphilitic  ulcer  remains,  the  floor  of  which  is  bone  denuded  of  its  perios- 
teum. This  bone  becomes  black  or  brown  where  it  is  exposed,  and  often 
a  superficial  flake  necroses,  separates  in  due  time,  and  comes  away,  after 
which  the  ulcer  heals.  On  the  skull  the  outer  table  comes  away  generally, 
the  inner  table  remaining,  perhaps  perforated  by  a  number  of  holes 
through  which  the  dura  mater  may  be  seen  and  felt. 

Sometimes  a  node  will  remain  as  a  hard,  fibrous  lump,  perfectly  pain- 
less, and  as  solid  as  wood  for  a  number  of  years,  causing  no  inconvenience. 
In  such  a  lump  bone-salts  are  not  deposited;  the  mass  consists  of  spindle 
•cells,  round  cells,  and  connective  tissue.  Such  a  node,  after  existing  for 
years,  may  suddenly  soften  and  melt  away,  involving  the  bone  in  destruc- 
tion, large  portions  of  the  superficies  of  which  necrose  in  the  floor  of  the 
ulcer.  I  have  seen  one  such  case  where  a  fibrous  syphilitic  node,  as  large 


186  THE    VENEREAL    DISEASES. 

as  an  egg,  remained  stationary  for  eleven  years  upon  a  man's  skull,  and 
finally  softened  after  a  severe  attack  of  typhoid  fever,  and  caused  the  loss 
of  a  number  of  square  inches  of  the  outer  table  of  the  skull. 

The  scars  left  by  nodes  which  have  softened  and  discharged  are  white, 
puckered,  attached  to  the  bone,  often  pigmented  at  the  circumference. 
The  loss  of  bone  by  necrosis  is  not  made  up,  but  the  old  bone  at  the  edges 
of  the  ulcer  may  be  thickened. 

Finally  and  most  commonly,  a  node,  having  existed  some  time,  under- 
goes partial  transformation  into  true  bone  in  its  under  layers  and  circum- 
ferential portions.  Such  new  formations  of  bone  cannot  be  removed  by 
treatment.  They  remain  permanent;  but  after  a  time  they  lose  their  sen- 
sitiveness and  constitute  simple  exostoses. 

Besides  periostitis  there  may  be  a  general  proliferative  osteitis  (usually 
of  a  long  bone)  involving  a  portion  or  the  whole  of  a  bone  in  a  painful 
general  thickening.  The  increase  in  size  remains  permanent. 

The  form  of  bony  outgrowth  due  to  syphilis  has  been  called  epiphy- 
sary  exostosis.  It  is  an  irregularly  shaped  ridge  or  prominent  peduncu- 
lated  bony  formation  occurring  about  the  epiphysary  ends  of  long  bones, 
recalling  the  outgrowths  seen  in  rheumatic  gout. 

Diagnosis  of  nodes  is  not  difficult.  When  young  and  soft  they  may 
possibly  be  mistaken  for  oedema  or  abscesses;  but  the  course  of  the 
growth,  and  particularly  the  nocturnal  pains,  suggest  a  search  for  a  syph- 
ilitic history,  and  put  the  physician  on  the  right  track  to  discover  the  na- 
ture of  the  affection. 

Treatment. — Nodes  respond  very  readily  to  treatment,  as  a  rule. 
The  iodides  are  called  for  in  doses  large  enough  to  control  nocturnal  pain. 
They  should  be  kept  up  for  several  weeks  or  months,  after  an  apparent 
disappearance  of  the  node  or  relapse  is  to  be  feared.  The  length  of  this 
after-treatment  depends  upon  the  age  of  the  node. 


DRY    CARIES. 

Virchow  has  described  this  affection  after  profound  study  of  the  path- 
ological process.  The  frontal  and  parietal  bones  of  the  skull  are  most 
often  involved;  indeed,  the  affection  is  almost  confined  to  the  cranium, 
the  external  table  alone,  or  both  tables  of  the  bone  being  implicated.  The 
outer  coat  of  the  blood-vessels  perforating  the  bone  is  the  matrix  in  which 
the  new  growth  of  cells  takes  place  in  caries  sicca,  as  shown  by  Rindfleisch 
and  Virchow.  This  new  cell-formation  is  gummatous.  Its  development 
by  pressure  causes  an  atrophy  of  the  bone  surrounding  the  vessel,  while 
at  the  outer  edge  of  the  little  collection  of  cells  the  subperiosteal  cell 
formation  lifts  the  periosteum,  and  therefore  does  not  cause  enough  pres- 
sure to  produce  atrophy.  This  circumferential  portion  of  the  little  tumor, 
therefore,  becoming  ossified,  creates  a  raised  ridge,  while  ultimately  that 
portion  of  the  minute  gumma  which  occupied  the  adventitia  of  the  vessel 
is  removed  by  absorption,  and  leaves  a  cavity  produced  by  the  previous 
atrophy  of  bone.  The  periosteum  sinks  into  this  cavity  and  adheres  to 
its  floor.  The  bone  surrounding  such  a  minute  depression  in  the  skull  and 
the  diploe  about  it  become  sclerosed. 

The  skull  sometimes  is  perforated  by  caries  sicca.  More  often  upon  the 
inner  table  localized  thickenings  of  bone  are  found  and  bony  osteophy  tes, 
with,  not  unfrequently,  fibrous  thickening  of  the  adherent  dura  mater. 


SYPHILIS    OF    LYMPHATIC    GLANDS,  ETC.  187 

Occasionally,  caseous  yellow  deposits  have  been  found  at  these  spots  at- 
taching the  pia  to  the  dura  mater. 

The  final  scar  in  the  bone  is  a  stellate,  puckered  depression,  with  an 
eburnated,  raised  border. 

Symptoms. — Caries  sicca  comes  on  only  in  late  syphilis,  and  an- 
nounces itself  by  localized  pain  without  swelling.  In  the  atrophic  stage 
the  worm-eaten  depressions  in  the  skull  may  be  readily  felt  through  the 
scalp.  They  are  pathognomonic  of  syphilis  and  by  themselves  are  suffi- 
cient to  establish  a  diagnosis.  Without  them  the  history  must  be  relied 
upon  in  the  main  for  diagnosis. 

Treatment  is  that  of  gumma  of  bone. 


GUMMA    OF   BONE. 

A  gummy  tumor  late  in  syphilis  may  form  anywhere  in  a  bone — under 
the  periosteum,  in  the  medullary  membrane,  interstitially  as  in  caries 
sicca. 

The  subperiosteal  gumma  is  found  chiefly  upon  the  clavicle,  skull, 
sternum,  ribs,  tibia,  ulna.  It  commences  like  a  node,  and  indeed  a  node 
is  a  gumma,  but  the  true  gummy  tumor  forms  more  rapidly,  is  less  diffuse, 
and  tends  always  to  soften,  while  the  less  active  node  tends  naturally  to 
remain  organized.  The  gumma  is  an  acute  process,  like  the  osteitis  and 
periostitis  already  described,  but  much  more  active.  Consequently,  it  is 
more  serious,  more  destructive. 

The  gumma,  commencing  like  a  node  and  advancing  rapidly,  softens, 
attaches  itself  to  the  skin  and  discharges,  its  puriform  debris  remaining 
as  an  ulcer  with  dead  bone  at  the  bottom.  The  pain  in  superficial  gumma 
of  bone  is  generally  slight,  or  absent  entirely.  Instead  of  discharging, 
gumma  of  bone  may  remain  a  soft  mass  for  a  time,  finally  becoming  cheesy; 
and  even  a  softened  gumma,  instead  of  discharging,  may  calcify. 

Gumma  of  the  medullary  membrane  in  the  long  bones  is  uncommon. 
It  is  usually  attended  by  intense  pain,  worse  at  night;  the  whole  bone 
swells,  and  finally  gives  way.  Ultimate  atrophy  of  the  portion  of  bone 
involved  is  to  be  expected. 

Medullary  gumma  of  the  short  bones  is  not  very  uncommon.  A  type 
of  such  formations  is  seen  in  dactylitis,  already  described  at  p.  175. 

The  diffuse  thickening  of  bone,  already  referred  to  in  connection  with 
syphilitic  osteo-periostitis,  is  often  a  gummatous  process,  the  connective 
tissue  around  the  vessels  permeating  the  bone,  in  the  Haversian  canals 
and  canalicules,  being  the  matrix  in  which  gelatinous,  gummatous  hyper- 
plasia  occurs,  afterward  drying  up  and  being  absorbed,  leaving  the  en- 
larged bone  very  porous,  or  remaining  degenerated  in  the  form  of  yellow 
or  cheesy  deposits. 

In  the  flat  bones,  and  particularly  in  the  diploe  of  the  skull-cap,  syph- 
ilitic gumma  takes  the  form  of  an  infiltration,  widening  the  bony  lacuna-, 
cutting  off  the  vitality  of  the  thin  plates  of  bone  involved,  and,  by  its 
gradual  increase,  separating  the  two  plates  of  condensed  bone  from  each 
other.  Finally,  a  piece  of  condensed  bone  may  die,  and  gradually  exfoli- 
ate. The  external  table  of  the  skull  over  a  considerable  area  may  perish 
in  this  way,  and,  when  the  necrosed  portion  has  exfoliated,  its  under 
surface  is  found  to  be  very  much  worm-eaten  and  roughened.  This  is  due 
to  the  nature  of  the  morbid  process  which  effects  the  separation.  At  the 
circumference  of  these  morbid  processes,  as  elsewhere  in  bone  syphilis. 


188  THE    VENEREAL   DISEASES. 

eburnation,  condensation,  and  thickening  of  bone  take  place  with  more  or 
less  tendency  to  osteophytic  and  hyperosteal  formations.  Sometimes  the 
inner  table  of  the  skull  necroses  in  connection  with  diffuse  gumma  of  the 
diploe,  leading  to  changes  in  the  dura  mater  and  brain,  and  to  the  most 
serious  nervous  symptoms. 

When  the  very  thin  bones  are  attacked  by  gummatous  changes  they 
ulcerate  and  in  part  necrose,  portions  of  dead  bone  coming  away  entire. 
This  is  the  rule  in  the  case  of  the  thin  bones  of  the  nose,  palate,  etc. 

The  disease  of  bones  in  these  regions,  indeed,  is  often  only  a  complica- 
tion of  gummatous  ulcers  commencing  in  the  soft  parts,  which,  during 
their  progress,  have  involved  the  bone.  The  same  result  sometimes  com- 
plicates gummatous  ulcers  of  the  integument,  as  already  detailed  (p.  162); 
but  the  bones  of  the  nose  are  peculiarly  liable  to  destruction  from  syphi- 
litic processes,  a  fact  well  known  among  the  laity,  who  look  upon  every 
destructive  disease  of  the  nose  as  an  evidence  of  syphilis,  and  generally 
expect  that  any  one  with  syphilis  stands  in  hourly  danger  of  losing  his 
nose — assumptions  as  false  as  they  are  general. 

As  secondary  results  of  the  changes  in  bone  produced  by  syphilis, 
may  be  mentioned  a  fragility  of  the  porous  bone,  rendering  its  fracture 
very  easy,  and  its  repair  slow  and  imperfect.  Damage  may  also  be  caused 
through  pressure,  by  hyperostoses,  upon  soft  parts,  cranial  nerves,  spinal 
nerves,  the  eye  in  orbital  exostosis. 


MERCUBY    AS   A    CAUSE    OF   BONE    DISEASE. 

Finally,  it  is  necessary  to  emphasize  the  fact  that  mercury  has  nothing 
to  do  with  disease  of  the  bone.  The  cry  with  many  in  the  profession  and 
nearly  all  among  the  people  is,  mercury  destroys  the  bones.  Very  intelli- 
gent men  coolly  sit  down  and  state  that  they  are  unwilling  to  take  mer- 
cury for  their  symptoms,  for  fear  that  their  bones  will  become  diseased; 
and  medical  men  keep  up  the  terrorism  of  the  people  by  attempting  to 
cure  syphilis  without  mercury.  No  statement  is  more  unfounded  in  fact 
than  that  the  syphilitic  bone  symptoms  of  syphilis  are  caused  by  mercury. 
The  node  of  the  skull,  mentioned  at  p.  185,  which  softened  after  typhoid 
fever,  and  swept  away  the  outer  table  of  half  a  parietal  bone,  occurred  in 
the  person  of  a  physician  in  the  country  who  was  afraid  of  mercury,  and 
never  had  taken  it  for  his  disease.  Nodes  and  bone  disease  occur  in  all 
forms  of  practice.  Patients  treated  without  mercury  frequently  suffer 
very  seriously  from  bone  syphilis.  Patients  in  Norway,  who  have  been 
"syphilized"  and  taken  no  medicine  for  their  disease  at  all,  certainly 
suffer  from  bone  syphilis,  as  Boeck  himself  has  remarked  to  me;  and 
finally — most  convincing  proof — the  bone  lesions  of  inherited  syphilis  are 
so  common  as  to  be  almost  uniform  in  their  occurrence,  in  greater  or  less 
intensity,  and  surely  the  unborn  babe  has  had  little  chance  of  exposure  to 
the  supposed  noxious  influence  of  mercury. 

Mercury  given  in  excess  to  the  point  of  salivation  may,  and  cer- 
tainly does,  threaten  the  maxillary  bones,  especially  the  alveolar  process, 
with  destruction;  but  aside  from  this,  mercury  does  not  cause  any  symp- 
toms which  might  be,  and  usually  are,  produced  by  the  poison  of  syphilis. 

The  researches  of  Kussmaul '  concerning  the  influence  of  mercury  upon 
workers  in  the  metal,  settle  this  question  from  one  standpoint,  while  hon- 

1  Untersuch.  iiber  d.  const! t.  MercurialismuB.    Wiirzburg,  1861. 


SYPHILIS    OF    LYMPHATIC    GLANDS,  ETC.  189 

est  clinical  observation  settles  it  with  equal  force  from  another.  Tho 
traditions  of  the  people,  and  the  ignorance  of  some  and  quackishness  oi 
others  in  the  profession,  are  responsible  for  the  continuance  of  this  error. 
Mercury  given  in  a  proper  manner  does  no  ultimate  harm  to  the  individual, 
and  sometimes  bone  symptoms  will  get  well  more  promptly  under  mer- 
cury than  under  the  iodides. 

Treatment. — As  a  rule,  all  forms  of  bone  disease,  from  the  painful 
spot  to  the  gumma,  respond  to  the  iodides.  Mercury  is  also  beneficial, 
especially  in  osteocopic  pains  and  all  lesions  occurring  early  in  the  dis- 
ease; but  in  the  true  gumma,  and  in  the  node  of  tertiary  syphilis,  mercury 
can  generally  be  dispensed  with,  and  full  reliance  placed  upon  large  doses 
of  the  different  iodides.  Sometimes,  when  the  iodides  fail,  or  after  a  time 
cease  to  act,  mercury  becomes  efficient  in  removing  the  morbid  process, 
even  when  it  is  gummatous;  but  mercury  certainly  holds  the  second  place 
in  most  cases. 


SYPHILIS    OF    CAETILAGE. 

Cartilage  of  incrustation  does  not  suffer  immediately  from  syphilis. 
When  a  joint  is  involved,  or  syphilis  attacks  the  expanded  end  of  a  bone 
capped  by  cartilage,  the  latter  naturally  softens,  becomes  eroded,  and  is 
destroyed  by  the  neighboring  disease.  Of  the  other  cartilages,  the  fibro- 
cartilage  of  the  ear  is  often  invaded  by  an  ulcerative,  tubercular  syphilide 
starting  in  the  superficial  tissues.  The  laryngeal  cartilages  are  a  very 
common  seat  of  syphilitic  perichondritis,  occasionally  gummatous  deposits 
involve  their  vitality,  and  portions  of  the  cartilage  may  fall  into  necrosis, 
just  as  a  bone  does  under  similar  circumstances.  The  trachea  may  be 
implicated  in  the  same  manner.  Gummata  upon  the  costal  cartilages  act 
like  the  same  lesions  on  bone.  The  inter- vertebral  fibro-cartilages  are  rarely 
ever  attacked,  but  sometimes  they,  as  well  as  the  bones  of  the  vertebral 
column,  are  involved  in  gummatous  processes. 


CHAPTER  XL 

SYPHILIS  OF  THE  RESPIRATORY   SYSTEM. 

THE   DIGESTIVE   TBACT,  ABDOMINAL   GLANDULAR  ORGANS,  AND   THB   VASCU- 
LAR  SYSTEM. 

Syphilis  of  the  Nose.— Syphilis  of  the  Larynx  ;  non-Ulcerative— Ulcerative. — Syphilis 
of  the  Trachea,  Bronchi,  and  Lungs.  — Syphilis  of  the  Digestive  Tract.  — Gumma 
of  the  Tongue. — Syphilis  of  the  (Esophagus. — Syphilis  of  the  Stomach  and  Intes- 
tines.— Syphilitic  Stricture  of  the  Rectum. — Syphilis  of  the  Peritonaeum. — Syphilis 
of  the  Pancreas. — Syphilis  of  the  Liver. — Diffuse  and  Circumscribed  Hepatitis. — 
Gamma  of  the  Liver;  Amyloid  Degeneration. — Syphilis  of  the  Spleen. — Syphilis 
of  the  Thymus,  of  the  Supra-renal  Capsules,  and  the  Abdominal  Glands. — Syphilis 
of  the  Heart. — Syphilis  of  the  Arteries,  Veins,  and  Capillaries. 

IN  the  nose,  in  early  syphilis,  erythematous  lesions  and  mucous  patches 
are  apt  to  occur.  Their  symptoms  are  those  of  catarrh,  with  more  or 
less  discharge,  some  scabbing  within  the  nose  and  ulceration,  more  or 
less  redness,  with  thickening  and  fissuring  at  the  orifice  of  the  nose. 
Young  people  suffer  more  than  adults  from  nasal  symptoms,  and  babies 
with  inherited  disease  most  of  all.  The  mucous  patch  and  the  erythe- 
matous lesions  have  the  same  physical  characteristics  here  as  they  have  in 
the  throat  (p.  166). 

In  tertiary  syphilis,  gummatous  ulcers  upon  the  mucous  membranes  of 
the  nose  involve  its  cartilages  below  and  its  thin  bones  above  in  destruc- 
tion; and  gummy  tumors,  originating  either  subcutaneously  or  within  the 
cavity  of  the  nose,  are  quite  certain  to  destroy  the  bridge  and  large  por- 
tions of  the  internal  bony  skeleton  of  the  nose,  unless  arrested  by  treat- 
ment. After  cure  in  these  cases,  the  bridge  of  the  nose  is  permanently 
sunken,  and  its  point  turned  up,  giving  a  physiognomy  which  is  almost 
pathognomonic  of  late  syphilis. 

While  the  destructive  process  involving  the  bone  is  going  on  within 
the  nose,  the  patient  has  what  is  called  syphilitic  ozena.  This  is  a  catarrh 
more  or  less  purulent  in  character,  the  pus  being  usually  mixed  with  blood. 
Often  blood-scabs  may  be  blown  from  the  nose,  or  drawn  down  into  the 
pharynx  through  the  posterior  nares.  The  odor  of  the  breath  in  these 
cases  is  peculiarly  offensive.  On  examining  the  inside  of  the  nose,  while 
the  process  is  going  on,  yellow  and  black  dry  scabs  are  found  closely  ad- 
hering to  ragged  edges  of  ulcers,  or  to  perforations  through  the  septum 
or  elsewhere.  Sometimes  there  is  considerable  pain  complained  of  in  these 
cases,  especially  at  night;  often  there  is  little  or  none.  Thin  pieces  of 
bone  are  frequently  discharged  through  the  nostrils,  and  the  malady  is 
often  kept  up  long  after  the  dead  pieces  of  bone  have  separated,  on  account 
of  the  fact  that  these  sequestra,  being  partly  enclosed  in  new  bone,  cannot 
escape  and  remain  like  splinters  in  a  fester  to  keep  up  the  local  irritation. 

In  connection  with  the  inflammatory  changes  accompanying  gummatous 


SYPHILIS    OF   THE    RESPIRATORY    SYSTEM,  ETC.  191 

disease  within  the  nasal  cavity,  the  nasal  duct  often  gets  shut  up,  leading 
to  abscess  of  the  lachrymal  sac,  conjunctivitis,  necrosis  of  lachrymal  bone. 
Again,  the  Eustachian  tube  may  be  closed,  and  inflammatory  trouble  in  the 
middle  ear  be  set  up,  leading  to  deafness. 

If  the  disease  is  situated  high  up  in  the  nasal  cavity,  the  olfactory 
sense  may  be  destroyed  or  temporarily  impaired. 

The  diagnosis  of  the  lesions  above  described  rests  upon  their  course 
and  obvious  clinical  characters.  No  other  disease  behaves  in  like  manner. 
There  is,  however,  one  condition  which  may  be  readily  mistaken  for  syphi- 
lis in  the  nose,  namely,  a  round  perforation  of  the  cartilaginous  septum, 
low  down,  generally  about  the  size  of  a  lead-pencil.  I  have  encountered 
this  several  times  as  a  result  of  catarrh  (apparently)  in  patients  who  un- 
doubtedly were  not  syphilitic.  I  have  known  a  patient  to  possess  this  de- 
formity and  to  be  ignorant  of  it,  and  have  seen  it  diagnosticated  as  syphi- 
litic, much  to  the  patient's  distress  of  mind.  The  borders  of  this  round 
hole  cicatrize,  and  it  causes  no  discomfort.  I  have  seen  the  hole  a  num- 
ber of  times,  but  never  during  its  forming  stage. 

The  treatment  of  tertiary  lesions  of  the  nasal  cavity  is  by  the 
iodides  in  large  doses.  Local  treatment  is  unreliable,  and  generally  un- 
necessary, until  it  becomes  evident,  by  the  use  of  the  probe,  that  there  is 
a  loose  piece  of  dead  bone  ready  to  come  away,  but  detained  by  surround- 
ing healthy  tissues.  For  the  removal  of  these,  I  know  of  nothing  so  ser- 
viceable as  the  dental  burr  upon  one  of  White's  dental  engines.  I  have 
seen  this  instrument  used  with  great  success  in  these  cases,  by  Dr.  Good- 
willie,  of  this  city. 

SYPHILIS    OP   THE    LARYNX. 

The  mucous  membrane  of  the  larynx  suffers  from  erythema  and  mu- 
cous patches  in  early  syphilis.  The  latter  have  been  repeatedly  seen 
in  the  larynx  by  aid  of  the  laryngoscope.  These  lesions  are  the  same 
here  as  elsewhere  on  the  mucous  membranes  (as  already  described). 
They  are  the  better  for  local  treatment,  but  get  well  without  it.  Mercu- 
rial inhalations  sometimes  hasten  their  disappearance.  They  leave  no 
scars  behind. 

The  syphilitic  laryngitis  which  interests  the  practitioner  is  the  ter- 
tiary variety.  It  occurs  in  a  constructive  and  in  a  destructive  form  in 
the  cartilages  of  the  larynx,  and  as  tertiary  gummatous  ulcerations  upon 
the  mucous  membrane,  the  vocal  cords,  and  in  the  muscles  of  the  larynx. 

Non-ulcerative  laryngitis,  due  to  syphilis,  is  a  chronic,  construc- 
tive, connective-tissue  hyperplasia,  involving  the  cords  as  well  as  all  the 
tissues  within  the  larynx.  The  newly-formed  material  contracts  here  as 
elsewhere,  binds,  and  draws  together  the  tissues  within  the  larynx,  stiff- 
ens the  vocal  cords  into  unyielding  rigidity  in  the  closed  state,  and, 
finally,  may  obstruct  respiration  entirely,  no  previous  ulceration  having 
occurred.  The  cartilages  do  not  become  necrotic  in  this  affection,  and 
there  is  no  loss  of  tissue,  except  of  muscular  tissue,  by  atrophy  from 
pressure. 

The  symptoms  of  this  affection  are  a  hoarseness,  lasting  for  months, 
even  years,  slight  pain  on  pressure  over  the  larynx,  gradually  increasing 
dyspnoea,  the  voice  finally  being  reduced  to  a  whisper,  the  patient  be- 
coming enfeebled,  cyanotic,  emaciated,  gasping,  praying  for  death  to 
relieve  him  from  his  distress.  The  laryngoscope  finds  the  larynx  stenosed. 
the  mucous  membrane  livid,  the  intra-laryngeal  tissues  thickened,  but 
shows  no  ulceration  and  no  cicatrices.  Rapid  oedema  of  the  glottis  is 


192  THE    VENEREAL    DISEASES. 

liable  to  come  on  at  any  time  in  this  affection,  and  quickly  to  strangulate 
the  patient. 

The  diagnosis  is  with  chronic  laryngitis — a  malady  which  is  always 
tubercular  or  pseudo-tubercular,  when  not  syphilitic.  In  the  former  case 
there  is  generally  consolidation  at  the  apex  of  the  lung,  and  the  laryngo- 
scope generally  detects  surface  ulceration  in  the  larynx.  Papilloma  of 
the  vocal  cords  gives  all  the  symptoms  of  syphilitic  laryngitis.  Diagno- 
sis with  the  laryngoscope  is  easy — without  it,  next  to  impossible. 

Treatment  is  mixed — mercury  with  the  iodides.  It  must  be  long 
continued.  If  commenced  early,  it  is  promptly  curative;  later,  it  is 
slower  in  its  action,  and  less  effective.  In  the  stage  of  stenosis,  trache- 
otomy is  sometimes  necessary,  to  avoid  impending  suffocation.  In  such  a 
case,  a  permanent  tube  must  be  worn  until  treatment  makes  it  safe  for 
the  patient  again  to  breathe  through  his  larynx.  I  have  tracheotomized 
a  patient  on  one  occasion,  in  this  condition,  who  was  cyanotic,  and  in  the 
last  stages  of  suffocation.  Two  silver  tubes  were  worn  out  in  as  many 
years;  but,  under  treatment,  the  patient  finally  recovered  entirely,  and 
dispensed  with  the  tube. 

Tertiary  ulcerative  laryngitis  may  accompany  the  affection  last 
described,  or  occur  independently  of  it. 

The  ulcers  are  like  tertiary,  gummy  ulcers  of  the  pharynx,  already 
described,  and  may  occur  anywhere  within  the  larynx,  on  the  cords,  be- 
hind the  epiglottis,  running  down  in  connection  with  ulcers  in  the  throat, 
or  occurring  independently. 

The  ulcers  may  start  as  in  the  pharynx,  upon  the  surface  and  eat  in, 
or  a  gumma  may  form  beneath  the  perichondrium  of  a  larnygeal  cartilage 
and  eat  out;  in  either  case,  especially  the  latter,  a  portion  of  the  cartilage 
is  liable  to  be  involved  in  necrotic  changes  and  to  exfoliate.  A  gumma 
of  the  larynx  may  work  its  way  out  externally,  giving  rise  to  fistula. 

The  ulcers,  surrounded  by  considerable  oedema,  are  visible  with  the 
laryngoscope.  The  final  cicatrization  after  cure  in  these  cases  may  lead 
to  the  most  extensive  distortion  of  the  laryngeal  cavity,  or  even  to  its  ob- 
literation. 

The  symptoms  are  those  of  chronic  laryngitis  intensified.  Pain  is 
common,  with  expectoration  of  pus,  mixed  perhaps  with  blood  and  portions 
of  sloughy  tissue. 

Diagnosis. — The  symptoms  easily  localize  the  disease,  and  the  diag- 
nosis lies  with  ulcerative  tubercular  laryngitis  and  destructive  cancerous 
laryngitis.  In  the  former  affection  the  lungs  will  almost  always  be  found 
to  be  in  an  advanced  state  of  tubercular  disease,  and  in  the  latter,  the  non- 
ulcerated  masses  of  new  growth  can  often  be  seen  with  the  aid  of  a 
laryngoscope. 

Treatment  is  with  the  iodide  of  potassium  in  large  doses — very  large 
doses,  run  up  as  rapidly  as  the  stomach  will  take  it — for  an  imporant 
organ  is  threatened.  The  effect  of  treatment  is  often  brilliant.  Trache- 
otomy may  be  called  for  on  account  of  impending  suffocation  from  oedema. 
Cicatricial  changes  are  not  favorably  affected  by  treatment,  and  may  be 
so  seriously  obstructive  to  respiration  as  to  demand  tracheotomy  and  a 
permanent  tube. 

SYPHILIS   OP   THE    TRACHEA,    BRONCHI,    AND   LUNGS. 

The  trachea  and  larger  bronchial  tubes  are  subject  to  the  same  mor- 
bid conditions  as  the  larynx,  but  less  commonly  so.  Ulcerative  changes 


SYPHILIS    OF   THE   RESPIRATORY   SYSTEM,  ETC.  193 

in  the  trachea  occur  by  preference  low  down  near  the  bifurcation.  Ulcers 
on  the  surface  may  eat  through  the  trachea  into  surrounding  structures, 
the  aorta1  or  pulmonary  artery,*  but  such  accidents  are  exceptionally  un- 
common. 

The  symptoms  of  tracheal  syphilis  are  uneasiness  or  pain  behind  the 
sternum,  cough,  more  or  less  rales,  expectoration,  blood,  etc.,  tickling  in 
the  throat. 

The  diagnosis  is  with  tubercular  troubles,  and  rests  mainly  upon  the 
history  and  concomitant  symptoms. 

The  treatment  is  like  that  for  similar  conditions  in  the  larynx. 

The  lungs  are  affected  by  syphilis  in  two  ways:  in  the  form  of  diffuse 
connective-tissue  hyperplasia.  leading  to  consolidation  by  interstitial 
changes  in  the  parenchyma;  and  in  the  form  of  gummy  tumor. 

Syphilitic  pulmonary  fibrosis  is  very  common  in  inherited  dis- 
ease. It  is  often  generalized  in  both  lungs  in  the  infant.  In  the  adult 
it  is  more  commonly  circumscribed.  The  change  in  either  case  is  an  in- 
terstitial thickening  of  the  connective  tissue  between  the  air-cells,  which 
may  go  on  to  a  total  obliteration  of  the  latter  in  the  fibroid  transforma- 
tion of  the  new  cells,  and  cirrhotic  shrinkage  of  the  morbid  tissue. 

The  portions  of  lung  involved  in  the  disease  are  stiff,  non-crepitant 
upon  pressure,  solid,  depressed  below  the  level  of  the  surrounding  lung. 
They  cut  like  fibrous  tissue;  the  section  is  seen  to  be  interspersed  with 
yellow  points;  and  the  bronchial  tubes,  variously  dilated  and  contracted,  are 
found  with  thickened  yellowish  walls.  The  pleura  over  these  spots  is  apt 
to  be  involved  in  the  thickening. 

In  the  child,  when  the  whole  lung  is  diseased,  it  is  found  dense  and 
marbled  on  the  surface,  bearing  the  imprint  of  the  ribs.  The  solid,  almost 
fibrous  tissue  (white  hepatization  of  Virchow),  sinks  in  water,  and  the 
lung,  although  perhaps  partly  inflated  in  some  portion  less  diseased  than 
the  rest,  is  manifestly  unfit  for  respiratory  purposes.  The  bronchial 
glands  are  usually  enlarged  and  hard,  sometimes  with  central  cheesy  de- 
generation. 

The  symptoms  of  pulmonary  fibrosis  are  not  pathognomonic.  They 
have  been  the  subject  of  much  dispute,  which  cannot  be  reproduced  here. 
In  the  infant  the  changes  take  place  in  intra-uterime  life,  and  there  are 
no  symptoms  after  birth  except  dulness  on  percussion,  shortness  of 
breath  and  cyanosis,  if,  indeed,  the  infant  has  enough  lung-tissue  left  in  a 
distensible  condition  to  support  life  for  a  little  while.  In  the  adult, 
however,  the  symptoms  are  identical  with  those  of  chronic  phthisis. 
Any  portion  of  the  lung,  apex  or  base,  may  be  involved,  and  there  are 
usually  the  accompaniments  of  fever,  short  breath,  cowgh,  emaciation, 
night-sweats,  etc. 

The  diagnosis  in  the  adult  is  with  ordinary  phthisis.  The  history  is 
of  great  service  here,  because  syphilitic  fibrosis  is  often  very  dry  and 
the  breathing  in  it  harsh,  tubular — especially  the  inspiratory  sounds. 
There  may  be  little  or  no  fine  crepitation,  perhaps  no  rales  at  all.  In  re~ 
gard  to  dyspnosa,  haemoptysis,  and  the  character  and  quantity  of  the  sputa, 
there  is  no  agreement  among  authors.  My  own  experience  leads  me  to 
believe  that  these  signs  vary  in  different  cases  greatly.  I  have  seen 
haemoptysis  with  profuse  expectoration  and  little  dyspnoea,  in  a  case 
which  got  well  under  antisyphilitic  treatment;  and  the  opposite  state  of 

1  Wilks :  Trans.  London  Path.  Soc.     XVI.,  p.  52. 
'Kelly:  Ibid.     XVIII.,  p.  45. 
13 


194  THE    VENEREAL    DISEASES. 

great  dyspnoea,  with  dry  cough  and  no  blood,  is  certainly  common.  The 
possibility  of  the  origin  of  ordinary  phthisis  from  the  irritation  in  the  air- 
cells  and  fine  tubes,  produced  by  their  getting  filled  up  with  secretions, 
whidh  are  discharged  from  diseased  syphilitic  conditions  of  the  larynx 
and  trachea,  must  be  borne  in  mind. 

The  truth  is  that  diagnosis  always  rests  mainly  on  the  history,  and 
treatment  is  consequently  for  the  most  part  tentatively  experimental. 

Treatment  is  mixed  with  large  doses  of  the  iodides.  Mercury,  in 
mild  courses  long  continued,  is  of  very  great  value.  Entire  and  perma- 
nent cures  are  possible  in  this  disease,  when  occurring  in  the  adult. 

Gummata  in  the  lungs  may  coincide  with  fibrosis,  or  come  on  in- 
dependently. They  necessarily  go  on  to  destruction  of  the  tissues  they 
implicate.  They  are  rare  in  adult  life,  as  well  as  in  inherited  disease. 

The  gumma  is  the  same  here  as  elsewhere:  at  first  a  tumor  formed 
of  gray  succulent  cells,  then  getting  yellowish  white,  more  or  less  fibrous, 
surrounded  by  a  wall  of  condensed  connective  tissue;  finally,  being  ab- 
sorbed, leaving  a  depressed,  fibrous  cicatrix,  or  remaining  in  a  state  of 
cheesy  degeneration,  or  softening,  breaking  down,  becoming  puriform, 
and  discharging  its  debris  by  the  nearest  route  to  a  free  surface,  through 
the  assistance  of  the  ulcerative  process.  When  these  tumors  form  near 
the  surface  of  the  lung,  the  pleura  over  it  becomes  thickened  and  adher- 
ent to  the  costal  pleura. 

There  are  no  fixed  symptoms  for  gumma  of  the  lung.  The  tumor  is 
solid  at  first,  and  may  be  made  out  by  percussion,  if  it  is  large  enough.  It 
may  suppurate,  and,  discharging  into  a  bronchus,  leave  a  cavity  which  may 
be  revealed  by  physical  signs.  A  syphilitic  history  does  the  rest  to  estab- 
lish a  diagnosis.  There  is  no  pain,  and  the  subjective  symptoms  are  not 
at  all  distinctive.  General  health  may  be  fair,  or  cachexia  pronounced. 

Treatment  is  rapidly  effective  of  relief,  which  is  permanent  so  far  as 
the  tumor  itself  is  concerned.  The  iodides  in  large  doses  are  all  that  is 
required,  with  such  attentions  to  the  stomach  as  shall  insure  their  assimi- 
lation. 

SYPHILIS   OP   THE    DIGESTIVE   TRACT. 

The  secondary  and  tertiary  lesions  of  the  buccal  cavity  and  pharynx 
have  been  already  studied  in  connection  with  the  cutaneous  manifesta- 
tions of  the  same  periods  (Chapter  IX.). 


GUMMY   TUMOR   OF   THE    TONGUE.  f 

Gummatous  lesions  of  the  tongue  are  especially  important  and  worthy 
of  study,  because  they  frequently  come  on  long  after  all  evidences  of 
syphilis  have  disappeared,  and  are  so  suggestive  of  epithelioma  of  the 
tongue  as  to  require  oftentimes  much  care  to  arrive  at  a  differential 
diagnosis. 

A  gumma  may  commence  in  any  portion  of  the  tongue  except  its 
under  surface,  and  may  be  encountered  at  any  time  of  life.  Not  very 
unfrequently  it  is  bilateral,  or  there  may  be  multiple  foci  of  gummatous 
deposit.  The  gumma  commences  without  any  pain,  as  a  lump  deep 
among  the  muscles  of  the  tongue,  or  under  the  mucous  membrane;  never 
superficially  at  first,  like  an  epithelioma.  The  lump  grows,  the  mucous 
membrane  over  it  becomes  stretched  and  livid,  finally  the  tumor  softens 


SYPHILIS    OF   THE    RESPIRATORY    SYSTEM,  ETC. 


195 


centrally,  ulcerates  its  way  through  the  mucous  membrane,  and  remains 
open  as  a  gummatous  ulcer,  with  a  deep,  sloughy  cavity,  hard  base,  fis- 
sured, ragged,  thick,  abrupt  borders,  often  undermined  at  iirst,  but  always 
bound  down  and  adherent  later  on.  The  ulcer  progresses  slowly.  The 
course  of  the  affection  in  any  case  is  much  protracted,  but  the  tendency 
is  to  ultimate  self-limitation,  even  without  treatment,  if  the  general 
health  be  good;  and  to  cicatrization,  with  more  or  less  loss  of  tissue,  ac- 
cording to  the  extent  and  duration  of  the  ulcer. 

The  discharge  is  slight,  even  when  the  ulcer  is  at  its  height;  but  there 
is  considerable  dribbling  away  of  saliva.  Pain  is  absent  or  inconsiderable, 
and  the  functions  of  the  tongue  not  much  disturbed.  The  lymphatic 
glands  escape  implication,  or  are  involved  only  in  an  inflammatory  way. 
The  general  health  may  be  very  little  disturbed,  or  there  may  be  marked 
cachexia. 

The  diagnosis  is  with  epithelioma  of  the  tongue,  and  with  tubercular 
ulceration.  The  latter  is  very  little  known.  Portal,  Trelat,  Fereol,  have 
recorded  cases.  Dr.  Van  Buren  related  to  me  the  description  of  a  case 
which  he  saw  at  the  Hague,  in  the  summer  of  1876,  and  Millard,  in  the 
Lancet  of  May  25,  1878  (from  L'Union  medicale),  details  a  case  in  which 
there  were  about  a  hundred  separate  ulcers.  These  tubercular  ulcers  com- 
mence as  white  excoriations  without  antecedent  tumor.  The  excoriations 
enlarge  and  deepen.  Gelade  is  referred  to  as  speaking  of  a  case  where 
the  superior  maxilla  became  invaded  and  carious. 

These  tubercular  ulcers  advance  slowly  and  are  very  obstinate  and  hard 
to  heal.  Excision  of  the  tongue  has  been  performed  several  times  on  ac- 
count of  them,  and  the  wound  has  healed  kindly.  Nearly  always  the 
lungs  contain  cavities. 

The  differential  diagnosis  between  epithelioma  and  gumma  of  the 
tongue  can  be  best  presented  in  tabular  form.  I  have  abbreviated  a  table 
from  Fournier,  and  modified  it  as  follows: 


Diagnostic  Table. 


ULCERATED   EPITHELIOMA  OP   THE 
TONGUE. 

1.  Occurs  generally  late  in  life. 

2.  Possible  cancerous  antecedents. 

3.  The  ulcer  sometimes  occupies  the  seat 
of  former  icthyosis  of  the  tongue. 

4.  Commences  superficially  and  ulcerates. 


5.  Lesion  is  unique. 

6.  Occurs  on  any  part  of  the  tongue. 

7.  Edges  everted,  tuberculated,  irregular, 
bleeding  easily  when  touched,  or  spontane- 
ously. 

8.  Discharge  free,  ichorous,  putrid. 

9.  Pain   spontaneous,   shooting  toward 
ear  (Fournier). 

10.  Tongue  rigid,  painful,  functionating 
badly. 

11.  Microscopic  characters  those  of  epi- 
tkelioma. 


1.  Occurs  at  any  age. 

2.  Syphilitic  history. 

3.  Nothing  of  the  sort. 

4.  Commences  deep  in  the  tissues,  feel- 
ing like  a  bullet  beneath  the  mucous  mem- 
brane.    It  softens  centrally,  and  on  reach- 
ing the  surface,  discloses  a  deep  ulcer. 

5.  Sometimes  multiple  and  bilateral. 

6.  Found  only  on  the  back  and  sides  of 
the  tongue,  never  beneath. 

7.  Edges  abrupt,  uneven,  hard,  adherent, 
covered  with  slough,  not  tuberculated,  not 
bleeding  easily. 

8.  Discharge  slight. 

9.  Ulcer  usually  painless. 

10.  Functional  troubles  generally  slight. 

11.  Microscopic   characters  those   of   a 
degenerating  gumma. 


196 


THE   VENEREAL   DISEASES. 


ULCEKATED  EPITHBLIOMA  OP  THE 
TONGUE. 

12.  Lymphatic  glands  become  involved. 

13.  Antisyphilitic  treatment  of  no  value, 
possibly  harmful. 

14.  Termination:  death  by  cachexia  and 
inanition. 

15.  Returns  if  cut  out. 


ULCERATED  GUMMA  OP  THE  TONGUE. 


12.  Lymphatic  glands  generally  remain 
exempt. 

13.  Antisyphilitic    treatment    generally 
promptly  beneficial. 

14.  Death  does  not  occur  from  this  cause 
alone.    Spontaneous  cure  without  medicine 
possible. 

15.  Does  not  return  if  cut  out  entirely. 


Treatment. — Gumma  of  the  tongue  usually  yields  a  rapid  response 
to  iodide  of  potassium  in  large  doses,  if  the  remedy  is  given  before  the 
tumor  has  softened.  After  ulceration,  the  effect  of  treatment  is  less  ra- 
pidly brilliant,  but,  nevertheless,  is  generally  quite  prompt.  In  cachectic 
conditions,  and  when  the  stomach  will  not  bear  the  iodides,  the  result  of 
treatment  is  slow  and  often  unsatisfactory. 


SYPHILIS    OF   THE    (ESOPHAGUS. 

Ulcers  from  the  pharynx  occasionally  extend  into  the  oesophagus,  but 
gummatous  deposits  may  originate  in  the  cesophageal  walls. 

These  lesions  are  very  rare.  Their  symptoms  are  pain  on  swallowing, 
with  evidence  of  some  obstruction  in  the  canal.  When  the  ulcers  get 
well,  the  resulting  cicatrices  cause  stricture,  which  requires  treatment  by 
dilatation,  oesophagotomy,  or  gastrotomy.1  N 


SYPHILIS    OP   THE    STOMACH    AND    INTESTINES. 

Early  in  syphilis,  especially  during  the  fever,  nausea,  indigestion,  and 
other  functional  troubles  of  the  stomach,  are  not  uncommon.  Presumably 
there  is  erythema;  possibly  there  are  mucous  patches  in  this  stage, 

Thickening  and  ulceration  of  the  stomach  have  been  ascribed  to  ter- 
tiary syphilis,  but  have  not  been  clearly  defined. 

Late  in  syphilis,  with  the  cachexia  there  often  occurs  a  diarrhoea  char- 
acterized by  great  prostration,  and  by  the  obstinacy  with  which  it  resists 
medication.  Sometimes  black  stools  of  partly  digested  blood  will  be 
voided,  or  clots,  or  even  bright  blood  will  be  passed  in  variable  amounts. 
With  this  there  may  be  more  or  less  nausea,  vomiting,  inappetence,  at- 
tacks of  temporary  fever,  with  circumscribed  areas  of  pain  due  to  local- 
ized peritonitis  over  the  site  of  an  ulcer  in  the  intestines. 

This  diarrhoea,  and  all  of  these  symptoms  are  due  to  gummy  ulcers  of  the 
intestines.  Such  ulcers  may  be  single,  or  multiple,  and  may  occur  in  the 
small  or  the  large  intestines.  They  have  been  reported  by  a  number  of 
observers,  Meschede,  Oser,  Wagner,  Lancereaux,  and  others  ;  but  their 
occurrence  is  uncommon,  and  opportunities  of  observing  them  after  death 
quite  rare.  Meschede  found  pigmenteu  ulcers,  Oser  infiltration  of  Peyer's 
patches,  with  central  ulceration.  Klebs  2  quotes  a  case  from  Yirchow's 

1  But  little  is  known  of  syphilis  of  the  oesophagus.  Consult  Knott :  Pathology  of  the 
(Esophagus,  p.  156  et  seq.,  containing  West's  excellent  cases  from  the  Dublin  Quarterly. 
Dublin,  1878. 

*  Path,  Anat.,  2  Lief.,  S.  261  et  seq. 


SYPHILIS    OP   THE    RESPIRATORY    SYSTEM,  ETC.  197 

Archives,  where  fifty-four  ulcers  were  found  in  the  small  intestine  of  a 
syphilitic  man  of  3(5,  and  some  circular  stellate  scars  on  pigmented  bases, 
with  tough  fibrous  nodules  on  the  corresponding  peritoneal  surfaces. 
Klebs  refers  also  to  two  cases  of  gummy  submucous  growth  in  new-born 
children,  and  has  a  personal  case  of  numerous  intestinal  ulcers,  with  thick- 
ening of  the  peritoneal  surface,  in  a  man  dying  with  acute  symptoms. 

In  a  personal  case,  which  I  watched  with  Dr.  Van  Buren  during  a 
number  of  months,  in  which  the  patient  had  much  cachexia  and  pro- 
longed attacks  of  diarrhoea,  often  voiding  black  stools  looking  like  partly 
digested  blood,  death  finally  came  about  suddenly  from  the  giving  way  of 
one  of  the  ulcers  of  the  ileum  into  the  peritoneal  cavity.  Shock  termi- 
nated life,  attended  by  profuse  black  vomit.  A  large  amount  of  blood  was 
found  in  the  peritoneal  cavity,  intestines,  and  stomach.  A  circular  ul- 
cer, as  large  as  a  penny,  had  given  way,  having  cut  cleanly  through  the 
peritoneum. 

A  number  of  scars  of  other  ulcers  were  found,  round  and  oval,  the  in- 
testine being  somewhat  constricted  where  they  had  occurred.  The  mus- 
cular coat  had  been  involved,  but  not  eaten  through.  The  peritoneum 
under  these  ulcers  was  not  thickened,  the  scars  themselves  were  round, 
smooth,  flat,  not  puckered,  not  pigmented.  This  patient  had  also  had  an 
ano-rectal  syphiloma,  diagnosticated  during  life;  the  autopsy  showed  that 
this  affection  had  been  practically  cured,  although  traces  of  cicatricial 
change  were  visible  upon  the  mucous  membrane. 

Peyer's  patches  have  been  found  in  a  state  of  characteristic  syphilitic 
fibrosis  by  Forster  in  inherited  disease,  and  other  observers  have  found 
ulcers  and  fibroid  changes  in  the  small  intestine  in  inherited  syphilis. 

Syphilis  of  the  large  intestine  has  been  the  object  of  much  study,  es- 
pecially in  the  rectum.  In  the  colon,  syphilitic  ulcers  may  occasionally 
occur  ;  and,  when  these  are  situated  near  the  origin  of  the  rectum,  dysen- 
teric symptoms  are  the  result — a  dysentery  which  sometimes  yields  to  an- 
tisyphilitic  treatment.  The  contest  between  those  claiming  that  the  so- 
called  syphilitic  stricture  of  the  rectum — so  common  in  women,  so  very  rare 
in  the  male — is  always  the  result  of  chancroid,  and  the  advocates  of  a  true 
syphilitic  stricture  in  this  region,  is  practically  ended.  The  unbiased 
student  must  now  admit  that  syphilis  as  well  as  chancroid  does  cause  rec- 
tal stricture,  but  in  a  different  way.  Chancroid  in  the  female  is  generally 
due  to  the  accidental  poisoning  of  an  abrasion  at  the  anus  by  the  dis- 
charges from  a  vagina  already  the  seat  of  chancroid,  which  discharges  run 
from  the  posterior  vaginal  fourchette  over  the  anus,  as  the  patient  lies  upon 
her  back.  Such  an  ulcer  extends  up  the  anus,  lasts  a  long  time,  and, 
finally,  leads  to  stricture,  which  is  in  the  main  cicatricial. 

Syphilitic  stricture  is  not  at  all  analogous  to  chancroidal  stricture 
in  its  method  of  formation.  Fournier  calls  it  ano-rectal  syphiloma.  It  is 
due  to  an  infiltration  of  the  submucous  connective  tissue  of  the  rectum 
and  that  lying  between  the  muscular  elements,  and  is  dependent  on  active 
cell-proliferation.  The  lesion  is  slow  in  forming,  and  without  surface 
ulceration.  Eventually,  here  as  elsewhere,  this  tissue  becomes  fibrous 
in  character  and  contracts,  producing  a  dense  fibroid  stricture  without 
previous  ulceration  of  the  walls  of  the  gut.  Ulceration  of  the  mucous 
membrane  may  occur  in  connection  with  the  infiltration  of  the  wall  of  the 
intestine,  but  this  is  not  an  essential  part  of  the  malady. 

The  best  clinical  account  of  this  affection  is  given  by  Fournier.1     The 

1  Syphilome  ano-rectaL     Paris,  1875,  pp.  73. 


198  THE    VENEREAL   DISEASES. 

infiltration  comes  on  insidiously  with  some  loss  of  power  in  the  sphincter, 
a  discharge  of  mucus,  and  occasionally  a  little  blood  at  stool.  This  is 
followed  later  by  difficulty  of  defecation,  small  stools,  constant  mucous 
discharge,  and  all  the  symptoms  of  stricture. 

Examination  shows  a  series  of  livid,  flat,  semi-elastic,  non-ulcerated 
infiltrations  extending  from  the  outside  within  the  cavity  of  the  rectum 
and  up  the  gut.  There  may  be  outside,  besides  these  livid  infiltrations, 
flat  or  pedunculated  condylomata,  and  perhaps  ulcerated  mucous  patches. 
Occasionally  an  ulcer  extends  into  the  anus,  but  this  is  rare. 

The  finger  passed  through  the  sphincter  recognizes  that  this  muscle 
has  lost  a  good  deal  of  its  contractile  power,  from  infiltration  of  its  sub- 
stance with  the  syphilomatous  material.  Farther  up  the  gut  the  surface 
is  found  velvety,  of  livid  color,  excoriated,  and  often  the  seat  of  punctate 
congestion.  The  mucous  .membrane  seems  itself  soft,  but  to  be  bound 
down  upon  a  very  hard,  semi-elastic,  thickened,  underlying  tissue,  which 
is  rather  indistensible,  and  the  walls  of  the  gut  often  feel  as  if  they  were 
the  seat  of  infiltrations  in  the  shape  of  broad,  hard,  linear  bands,  running 
parallel  to  the  long  axis  of  the  gut  and  not  around  it,  as  in  ordinary 
fibrous  stricture. 

The  tightest  part  of  the  stricture  is  apt  to  be  above,  at  the  top  of  the 
new  formation.  The  last  phalanx  of  the  index  finger  can  generally  be  in- 
troduced through  it,  but  I  have  seen  it  situated  as  high  as  four  inches 
from  the  anus.  There  may  or  may  riot  be  surface  ulceration  at  the  top 
of  the  stricture  and  above  it.  After  syphiloma  of  the  rectum  has  lasted 
several  years  it  becomes  fibrous  and  unyielding,  often  very  tight. 

Trelat '  thinks  that  the  formation  of  dry  fistulae  below  the  point  of 
actual  stricture,  cicatrizing  shortly  after  they  form  and  extending  from 
just  without  to  just  within  the  anus,  are  pathognomonic  of  syphiloma  of 
the  rectum.  I  have  only  seen  this  once  among  perhaps  ten  cases  of  the 
affection  which  I  have  examined. 

Besides  the  ano-rectal  syphiloma  in  the  rectum,  syphilitic  ulcers  may 
exist,  due  to  the  ulceration  of  mucous  patches  at  the  anus,  and  such  ulcers 
may  destroy  considerable  tissue  and  lead  to  permanent  stricture  by  cica- 
trization. True  gummy  tumor  of  the  rectum  has  also  been  observed. 
Zeissl  has  reported  such  a  case. 

The  diagnosis  of  troubles  of  the  rectum  due  to  syphilis  is  very  diffi- 
cult. Great  differences  of  opinion  still  exist  in  the  profession  as  to  the 
possibility  of  pure  syphilitic  stricture  of  the  rectum.  The  stricture  of  the 
rectum  found  in  women  after  difficult  labor  in  early  life  seems  much  to 
resemble  the  ano-rectal  syphiloma,  excepting  that  in  the  former  the  flat, 
livid  infiltrations  around  the  anus  do  not  exist.  When  ulceration  has  pre- 
ceded stricture,  it  is  difficult  to  differentiate  the  chancroidal  form  from  that 
occasioned  by  ulcerated  mucous  patches. 

The  true  ano-rectal  syphiloma,  however,  is  easily  recognized.  No 
other  malady  produces  the  livid,  flat,  softish,  semi-elastic  external  patches 
extending  into  the  sphincter  and  weakening  its  power,  attended  by  the 
denser  infiltration  higher  up,  with  little  or  no  surface  ulceration  and  com- 
paratively little  pain. 

Treatment. — In  all  the  tertiary  syphilitic  affections  of  the  digestive 
tract  dietary  expedients  and  precautions  are  nearly  as  essential  as  spe- 
cific treatment.  The  effect  of  mercury  in  all  of  these  conditions  is  good; 
but  the  drug  should  be  administered  either  in  the  form  of  the  mercurial 

1  Le  prog,  med.,  Jane  22,  1878,  p.  473. 


SYPHILIS    OF   THE    RESPIRATORY    SYSTEM,  ETC.  199 

bath  or  by  inunction,  so  as  to  spare  the  stomach  and  intestines  as  much 
as  possible.  The  iodides  should  be  combined  with  the  mercurial  treat- 
ment. They  should  be  commenced  in  mild  doses  and  pushed  with  cau- 
tion, largely  diluted  with  water,  after  meals  consisting  of  boiled  rice  and 
boiled  milk,  preceded  by  large  doses  of  the  subnitrate  of  bismuth.  In 
this  way  the  obstinate  diarrhoea  of  tertiary  syphilis  maybe  often  checked, 
and  the  intestinal  ulcers  which  presumably  give  rise  to  it  often  brought 
to  a  successful  cicatrization. 

The  troubles  produced  by  syphilis  at  the  anus  and  in  the  rectum  re- 
quire local  as  well  as  general  treatment.  Mucous  patches  and  ulcers, 
whenever  they  occur,  demand  excessive  cleanliness,  washing  with  soap 
and  warm  water  and  careful  drying,  with  soft  rags.  After  this  there  is 
no  treatment  better  than  dusting  the  surfaces  freely  with  dry  calomel, 
lodoform  in  powder  is  also  excellent,  if  its  odor  is  not  objected  to,  and  the 
judicious  use  of  a  point  o'f  nitrate  of  silver  upon  the  ulcers  and  fissured 
creases  about  the  anus  materially  aids  the  rapidity  of  cure. 

For  ulcers  within  the  rectum  nothing  is  better  than  suppositories  of 
iodoform  from  four  to  eight  grains,  rubbed  up  with  butter  of  cacao  into  a 
soft  mass,  which  should  be  deposited  by  means  of  a  suppository  tube  and 
repeated  once  or  twice  a  day.  I  think  that  a  grain  or  even  two  grains  of 
mercurial  ointment  in  such  a  suppository  increases  its  efficacy  without 
producing  irritation.  Trelat  thinks  well  of  meshes  of  lint  soaked  in  gly- 
cerine containing  a  little  tannin  or  other  astringent,  introduced  into  the 
rectum.  In  syphilitic  stricture  of  the  rectum  stools  should  always  be  ob- 
tained by  the  aid  of  enemata,  preferably  a  thin  solution  of  flaxseed  tea. 
When  the  ano-rectal  syphiloma  is  advancing,  moderate  pressure  twice  a 
week,  used  very  gently  with  a  soft  bougie,  is  attended  by  comfort,  and,  I 
think,  some  advantage.  Later  on,  when  the  contraction  of  the  new  tis- 
sue is  producing  fibroid  changes  in  the  wall  of  the  gut,  the  bougie  is  indis- 
pensable; and  in  the  last  stage  of  unyielding  fibrous  contraction  linear  sec- 
tion of  the  whole  thickness  of  the  altered  tissue  with  the  knife,  ecraseur, 
or  electro-cautery,  alone  offers  a  chance  of  cure  and  holds  out  hope  of 
comfort  to  the  patient. 

At  any  stage  of  the  complaint  great  advantage  may  be  derived  from 
intelligent  treatment,  local  as  well  as  general.  In  the  case  referred  to  at 
page  197,  where  a  post-mortem  examination  confirmed  the  fact  of  cure, 
the  patient  had  already  been  subjected  to  two  cutting  operations  for  stric- 
ture of  the  rectum,  by  a  surgeon  who  had  not  recognized  the  cause  of  his 
trouble  and  had  cut  and  burned  away  the  flat,  external  anal  tumors.  He 
was  little,  if  at  all,  relieved  by  these  measures;  but  eventually  cured  of 
his  trouble  mainly  by  internal  means.  The  unfortunate  perforation  of 
one  of  his  intestinal  ulcers  terminated  the  case  and  allowed  an  inspection 
of  the  rectum,  although  material  improvement  in  this  direction  had  al- 
ready been  indicated  by  a  cessation  of  most  of  the  functional  derange- 
ments of  the  part.  In  another  personal  case  I  found  internal  and  local 
means  of  no  avail  until  I  had  divided  all  the  thickened  tissues  posteriorly 
with  the  knife,  under  ether,  to  the  extent  of  fully  four  inches  up  the  gut. 


SYPHILIS    OF   THE   PERITONEUM. 

Syphilis  generally  spares  the  peritoneum,  even  when  the  viscera  cov- 
ered by  this  membrane  are  attacked.  Often,  however,  in  connection 
with  syphilitic  (especially  gummatous)  changes  in  the  liver,  spleen,  intes- 


200  THE    VENEREAL    DISEASES. 

tines,  ovaries,  the  peritoneum  becomes  thickened  and  adherent  to  neigh- 
boring layers  of  peritoneum.  Interference  with  the  portal  circulation 
from  such  causes  might  occasion  ascites. 


SYPHILIS    OF   THE    ABDOMINAL    GLANDS. 

In  this  connection  all  the  glands  of  the  abdomen,  excepting  those  of 
the  genito-uriuary  system,  come  up  for  consideration. 


SYPHILIS    OP   THE    PANCREAS. 

This  gland,  like  the  salivary  glands,  is  very  rarely  touched  by  syphilis. 
Lancereaux  has  found,  after  death,  parenchymatous  connective-tissue 
proliferations  in  the  pancreas,  and  gummy  tumors  in  one  case;  and  Vir- 
chow  discovered  fatty  degeneration  in  inherited  disease.  Birch  Hirsch- 
feld1  found  the  pancreas  very  often  indurated,  in  autopsies  upon  cases  of 
inherited  syphilis. 

SYPHILIS    OF   THE   LIVER. 

The  changes  in  the  liver  due  to  syphilis  are  true  to  the  two  types  of 
syphilitic  tissue  alteration:  the  one  constructive — a  diffuse,  parenchyma- 
tous, cellular  hyperplasia,  ending  in  contraction  and  induration;  the 
other  destructive — the  gummy  tumor.  Amyloid  changes  in  the  liver  are 
also  ascribed  to  syphilis. 

Diffuse  syphilitic  hepatitis,  in  which  the  connective  tissue  of  the 
whole  gland  is  involved,  does  not  occur,  except  in  infants  with  inherited 
disease.  The  whole  gland  grows  large,  heavy,  hard,  of  a  flinty  gray  color, 
the  glandular  structure  being  more  or  less  obliterated — so  much  so  that,  in 
some  cases,  it  cannot  be  made  out  with  the  naked  eye.  The  new  tissue 
is  connective-tissue  hyperplasia  in  the  parenchyma,  and  new  cells  and 
nuclei  along  the  capillaries.  The  liver-cells  are  compressed,  distorted, 
atrophied  by  the  new-formed  tissue,  and  often  in  a  state  of  granular  de- 
generation. Softening  and  breaking  down  of  tissue  does  not  occur  in 
this  affection. 

On  opening  the  abdomen  of  a  child  dead  with  inherited  syphilis,  an 
enormous  liver  is  often  found,  which  has  undergone  the  changes  above 
detailed.  It  is  hard,  tense,  elastic.  A  piece  of  it,  cut  out,  slips  away 
when  pinched  between  the  thumb  and  finger.  The  organ  may  be  so 
dense  that  the  finger  can  only  bore  a  hole  in  it  with  difficulty.  Collapsed 
and  thickened  vessels  show  on  the  pinkish  brown  surface  of  section  as 
white  knots,  from  which  radiate  thin  whitish  streaks.  The  vessel-walls 
are  sometimes  the  seat  of  amyloid  degeneration.  A  dark  spot  may  mark 
an  obliterated  bile-duct.  The  contents  of  the  gall-bladder  are  sticky  and 
pale  (Gubler). 

In  a  circumscribed  form,  the  same  diffuse  parenchymatous  changes 
occur  in  the  liver  of  adults  with  acquired  syphilis.  It  goes  on  to  final 
atrophy  and  cirrhosis  of  the  part  involved,  the  cicatrix  formed  by  the 
wasted  tissue  contracting  deeply  into  the  organ.  If  many  of  these 
contracted  spots  exist  in  the  same  liver,  they  may  pull  it  down  into  very 

1  Archiv  f.  Heilkunde,  1875,  Heft  2. 


SYPHILIS    OF   THE    RESPIRATORY   SYSTEM,  ETC.  201 

small  dimensions,  the  liver-tissue  jutting1  out  between  the  puckered,  con- 
tracted spots  in  a  singular  manner.  The  tissue  in  these  limited  glandu- 
lar areas  may  be  normal,  or  in  amyloid  degeneration. 

The  cicatricial  circumscribed  areas,  representing  old,  diffuse  hepatitis, 
may  contain  cheesy  masses  at  their  centre,  such  as  are  left  behind  by 
the  degenerative  changes  affecting  true  gummata,  and,  indeed,  gummy 
tumors  may  coincide  with  the  diffuse  patches  of  syphilitic  parenchyma- 
tous  hepatitis.  The  peritoneum  over  the  depressed  cicatricial  areas  oc- 
cupying the  sites  of  old  disease,  is  generally  thickened.  Sometimes  the 
two  layers  of  peritoneum  are  adherent. 

Gummy  tumor  of  the  liver  occurs  as  a  dense,  connective-tissue, 
radiate  mass,  with  cheesy  deposits  scattered  through  it,  or  as  a  round, 
cellular  tumor,  degenerated  at  the  centre,  and  separated  from  the  liver 
substance  by  a  capsule  formed  of  condensed  connective  tissue.  Gummata 
commence  in  the  walls  of  the  vessels  between  the  lobules.  They  thus 
envelop  the  lobules,  which  they  destroy.  Virchow,  who,  with  Frerichs 
and  others,  believes  that  local  violence  has  something  to  do — as  an  im- 
mediate, exciting  cause — with  syphilitic  changes  in  the  liver,  has  called 
attention  to  the  fact  that,  in  the  line  of  the  suspensory  ligament  of  the 
liver,  a  broad  band  of  connective  tissue,  interspersed,  perhaps,  with  gum- 
mata, is  apt  to  extend  between  the  two  lateral  lobes,  looking  as  if  the  vio- 
lence done  to  the  tissue,  by  traction  upon  the  ligament  during  exercise, 
might  be  the  exciting  cause  of  the  changes  in  this  particular  locality. 

Gummata  of  the  liver  may  be  solitary  or  occur  in  great  numbers,  and 
of  varied  size,  interspersed  through  the  organ.  It  is  rare  for  them  to  soften. 
Wilks  and  Moxon  have  reported  cases  to  the  London  Pathological  Society. 
They  generally  undergo  fibro-molecular  and  cheesy  degeneration. 

Amyloid  and  fatty  degeneration  of  the  liver  are  found  in  connec- 
tion with  other  changes  due  to  syphilis,  or  independently  of  them.  Amy- 
loid degeneration  of  the  liver,  kidneys  and  spleen  is  so  often  encountered 
coincidently  with  syphilitic  cachexia  in  tertiary  disease,  that  the  change 
must  be  looked  upon  as  in  some  way  brought  about  by  syphilis,  although 
not  in  its  own  nature  syphilitic,  since  the  same  degeneration  occurs  in 
many  patients  who  are  not  at  all  syphilitic.  The  change  begins  in  the 
walls  of  the  small  arterioles,  and  may  continue  confined  to  the  vessel- 
walls. 

Symptoms  of  syphilis  of  the  liver. — The  changes  in  size  of  the 
liver  due  to  hepatitis  may  be  appreciated  by  percussion.  Inequalities  due 
to  extensive  cicatricial  puckering  of  the  organ  may  sometimes  be  made 
out  by  palpation.  Some  pain  may  be  complained  of,  but  as  a  rule,  symp- 
toms in  connection  with  syphilis  of  the  liver  are  very  moderate  or  absent 
altogether,  the  lesion  or  its  cicatrix  being  encountered  after  death.  Jaun- 
dice is  the  exception  rather  than  the  rule,  but  sometimes  comes  on  and 
lasts  long.  Jaundice  early  in  syphilis  may  be  due  to  catarrh  of  the  bile- 
ducts,  or  pressure  from  enlarged  lymphatic  glands.  Late  in  syphilis,  again, 
large  abdominal  lymphatic  glands  may  occasion  jaundice,  and  cicatricial 
contractions  may  do  the  same,  as  well  as  cause  ascites  late  in  syphilis. 

Such  digestive,  haemorrhoidal  and  anasarcous  troubles  as  accompany 
cirrhoses  of  the  liver  may  be  due  to  a  similar  condition  of  the  organ,  pro- 
duced by  syphilis.  Albuminuria  and  cachexia  often  accompany  syphilitic 
degenerative  changes  of  the  liver.  When  these  two  symptoms  coincide 
with  an  irregularity  of  form  and  indurated  lumps,  or  a  fissured  edge  of 
the  liver,  which  may  be  felt,  Lancereaux  considers  them  to  be  pathogno- 
monic  of  syphilis. 


202  THE    VENEREAL   DISEASES. 

Treatment  is  that  of  late  syphilis  in  the  adult — a  mixed  medication 
with  a  preponderance  of  the  iodides,  especially  if  there  is  reason  to  sus- 
pect that  the  lesion  is  gummatous.  In  the  infant,  treatment  by  inunction 
is  appropriate;  but  not  much  can  be  expected  from  it  if  the  malady  be  far 
advanced. 

SYPHILIS    OF    THE    SPLEEN. 

Four  varieties  of  textural  change  may  be  produced  in  the  spleen  by 
syphilis:  (1)  a  parenchymatous  diffuse  splenitis,  general  or  partial;  (2) 
gummy  tumor;  (3)  an  increase  in  the  pulp  of  the  organ;  (4)  amyloid  de- 
generation. 

The  parenchymatous  change  is  a  diffuse,  connective-tissue,  cellular  hy- 
perplasia,  going  on  to  the  formation  of  fibres  which  contract  and  leave 
pale,  depressed  spots,  with  the  peritoneum  over  them  adherent  to  neigh- 
boring organs. 

The  gummata  are  fibrous  nodules  of  varying  size,  cellular  and  fibrous 
at  the  circumference,  granular  and  degenerated  centrally;  pinkish  gray  at 
first,  finally  a  dirty,  yellowish  white. 

The  amyloid  degeneration  coincides  with  similar  changes  in  the  liver 
and  kidneys. 

The  increase  in  the  pulp  has  been  noticed  by  Lancereaux,  and  doubt- 
less is  the  condition  which  prevails  in  the  enlargements  observed  early  in 
syphilis  by  Weil  and  Weber,  and  in  the  soft  enlargement  of  the  spleen 
described  by  Virchow. 

In  inherited  disease,  the  spleen  may  be  larger  and  harder  than  usual, 
but  gummata  are  rarely  found  in  it.  Eisenschutz  '  thinks  that  enlarge- 
ment of  the  spleen,  easily  detected  by  palpation,  is  a  diagnostic  symptom 
of  latent  inherited  syphilis. 

Symptoms. — There  are  no  symptoms  of  enlarged  spleen  due  to  syphi- 
lis, unless  the  anaemia  of  the  first  period  is  in  some  way  due  to  it.  Weil s 
has  called  attention  to  an  enlargement  of  the  spleen,  which  he  states 
comes  on  very  constantly  in  the  early  stages  of  acquired  syphilis,  and  dis- 
appears under  treatment;  and  Weber3  reports  that  this  enlargement  may 
be  detected  between  the  eighth  and  the  twelfth  week  after  infection;  in 
most  cases,  in  from  one  to  two  weeks  after  the  appearance  of  general 
symptoms.  It  is  said  to  continue  for  from  one  to  two  months,  and  to  be 
favorably  influenced  by  mercurial  treatment. 


SYPHILIS   OF  THE    THYMUS,  THE    SUPEA-RENAL    CAPSULES,  AND  THE  ABDOM- 
INAL  LYMPHATIC    GLANDS. 

The  thymus,  which  usually  atrophies  as  the  child  develops,  in  inher- 
ited disease  has  been  found  hardened,  enlarged,  broken  down  centrally 
into  a  puriform  material,  the  seat  of  diffuse  connective-tissue  hyperplasia, 
and  of  gumma. 

Enlargement,  gummata,  and  fatty  degeneration  of  the  supra-renal  cap- 
sules, are  met  with  in  acquired  syphilis. 

1  Das  latente  Stadium  der  hereditaren  syphilis.  Wien.  med.  Wochenschrift,  48,  49, 
1873. 

*  Denfesoh  Archiv  f.  klin.  Med.,  May  15,  1874. 
1  Ibid.,  4,  5,  1876. 


SYPHILIS    OF   THE    RESPIRATORY    SYSTEM,  ETC.  203 

In  neither  of  these  conditions  are  there  any  positive  symptoms  causing 
the  affection  to  be  recognized  with  certainty  during  life. 

The  abdominal  lymphatic  glands  are  subject,  in  late  syphilis,  to  con- 
siderable enlargement  and  to  gumrnatous  deposits,  which  may  atrophy  or 
become  amyloid,  or  cheesy,  or  may  soften  and  discharge,  generally  upon 
the  cutaneous  surface,  leaving  ulcers  and  fistulous  channels  of  varying  ex- 
tent and  duration.  The  pressure  of  these  larger  glands  may  interfere  with 
digestion  or  give  rise  to  jaundice. 

Such  glandular  swellings  may  be  diagnosticated  when  they  can  be  felt, 
and  are  best  treated  by  the  iodides,  with  a  certain  amount  of  mercury  by 
inunction. 

SYPHILIS    OF   THE    VASCULAR   SYSTEM. 

All  parts  of  the  vascular  system  are  liable  to  suffer  from  syphilitic  le- 
sions; the  heart  most  frequently,  the  veins  very  seldom. 

Syphilis  of  the  heart. — A  diffuse  pericardial  thickening  and  a  gumma 
of  the  pericardium  have  been  occasionally  noted  after  death.  Wagner 
has  described  as  syphilitic  certain  miliary  granules  found  on  the  pericar- 
dium. 

Diffuse  parenchymatous  myocarditis  also  occurs,  and  most  often,  either 
with  the  diffuse  cellular  infiltration  or  independently,  gumma  of  the  mus- 
cular structure. 

Grenouiller,1  in  a  thesis  on  cardiac  syphilis,  drawing  his  conclusions 
from  twenty-four  cases,  collated  from  various  sources,  finds  that  syphi- 
litic myocarditis  generally  commences  as  a  small  gumma,  and  ends  as  a 
patch  of  sclerosis.  Gummy  tumor  was  found,  in  eighteen  out  of  the  twenty- 
four  cases,  once  during  the  first  year  after  infection — at  an  average,  how- 
ever, of  ten  years.  The  thick  wall  of  the  left  ventricle  was  the  commonest 
seat  of  the  deposit.  There  were  no  special  symptoms  during  life,  although 
heart  disease  was  sometimes  suspected.  About  two-thirds  of  the  cases 
terminated  in  sudden  death. 

Anatomically,  the  gumma  of  the  heart  is  a  collection  of  small  round 
cells  (like  a  sarcoma),  encapsulated  and  yellowish  white  on  section,  often 
cheesy  at  the  centre.  If  near  the  surface,  the  pericardium  or  endocardium 
over  them  is  thickened.  They  are  often  multiple. 

A  general  weakening  of  the  heart's  action,  without  any  valvular  irreg- 
ularity, attended  by  slight  enlargement  of  the  organ  and  dilatation  of  its 
cavities,  seems  to  be  the  only  symptom  upon  which  a  diagnosis  can  be 
based.  Lancereaux  believed  that  he  diagnosticated  one  case  which  got 
well  under  treatment. 

The  possibility  of  embolism,  due  to  bursting  of  a  softened  gumma  into 
the  cavity  of  the  heart  (Oppolzer,  Lancereaux),  must  be  remembered. 

Treatment  is  mixed,  with  preponderance  of  the  iodides. 

Syphilis  of  the  arteries. — The  arterial  lesions  of  syphilis  have  been 
the  object  of  much  study  during  the  past  few  years.  Gelatinous  nodules, 
growing  from  the  middle  coat  of  the  pulmonary  artery,  have  been  found, 
and  smooth,  softish  tubercles,  all  presumably  syphilitic.  The  changes  in 
the  large  vessels,  however,  which  are  most  common,  are  atheromatous  de- 
posits; and  these,  when  they  are  found  in  a  syphilitic  subject  early  in  life, 
before  they  can  be  accounted  for  by  senile  changes,  are  generally  set  down 
as  being  due  to  syphilis. 

1  Paris,  1878. 


204  THE    VENEREAL   DISEASES. 

A  diffuse  general  thickening  of  the  arterial  wall,  commencing  (Heub- 
ner)  as  an  endo-arteritis,  and  sometimes  going  on  to  the  extent  of  occlud- 
ing the  lumen  of  the  vessel,  appears  to  be  a  process  very  common  among 
the  small  arteries  in  syphilis,  especially  the  arteries  of  the  brain  (Heub- 
ner),  although  other  causes  besides  syphilis  may  produce  this  same  arte- 
rial thickening  (Cornil,  Ranvier,  Koster,  Friedlander).  Lancereaux  and 
others  have  observed  this  thickening  of  the  vascular  wall  to  a  marked  ex- 
tent in  the  carotids. 

As  a  consequence  of  syphilitic  arterial  changes,  brain  symptoms 
(Heubner)  are  not  uncommon,  due  to  a  cutting  off  of  a  portion  of  the 
brain  from  its  blood-supply  on  account  of  partial  or  entire  closure  of  the 
lumen  of  an  artery  through  thickening  of  its  walls.  Cerebral  apoplexy  is 
sometimes  due  to  syphilitic  arterial  changes,  and  pulmonary  apoplexy  as 
well  (Weber),  while  aneurisms  are  so  much  more  common  upon  syphilitic 
patients  than  upon  others,  that  the  relation  must  be  more  than  mere  coin- 
cidence. 

There  are  no  positive  diagnostic  signs  by  which  the  syphilitic  nature 
of  a  presumed  or  a  positive  (aneurism)  arterial  change  can  be  established. 
When  such  changes  occur  upon  a  syphilitic  subject,  a  mixed  treatment, 
with  a  preponderance  of  the  iodides,  is  indicated.  The  effect  of  treatment 
upon  arterial  lesions  is  not  brilliant;  but  often  treatment  is  of  enough 
value  to  make  it  well  worth  while  to  push  it  with  firmness  and  continue 
it  with  long  patience. 

Of  the  effect  of  syphilis  upon  the  veins,  little  is  known.  J.  Hutchin- 
son,  in  his  report  on  syphilis  to  the  London  Pathological  Society,  thinks 
that  he  has  observed  inflammatory  changes  about  varices  and  around 
healthy  veins  in  syphilitic  subjects  quite  frequently,  and  he  infers  that 
these  sometimes  must  be  of  specific  nature. 

Of  the  capillaries  it  may  be  stated  that  their  external  walls  are  the 
habitual  starting-points  of  gummatous  tumors,  and  Lancereaux  states 
that  their  walls  become  fatty  in  conditions  of  syphilitic  cachexia. 

The  amyloid  changes  found  in  late  syphilis  attending  the  cachectic  stage 
commence  usually  in  the  walls  of  the  blood-vessels,  generally  the  smaller 
ones,  and  sometimes  remain  confined  to  them. 


CHAPTER  XII. 

SYPHILIS  OF  THE   NERVOUS   SYSTEM. 

General  Pathology  of  Nervous  Syphilis. — Syphilis  of  the  Brain,  Pachymeningitis,  Gum- 
mata  of  the  Meninges,  Encephalitis,  White  Softening,  Gummata  of  the  Brain. — 
Syphilis  of  the  Cerebral  Arteries. — General  Symptoms  of  Brain  Syphilis,  Prognosis, 
Treatment. — The  Special  Aifections  produced  by  Syphilitic  Lesions  of  the  Brain. — 
Syphilitic  Hemiplegia,  Epilepsy,  Generalized  Paralysis,  Catalepsy,  Chorea,  Aphasia, 
Insanity. — Brain  Syphilis  simulating  Sunstroke  often  followed  by  Desire  to  Sleep. 
— Syphilis  of  the  Cord. — Syphilitic  Paraplegia. — Syphilitic  Locomotor  Ataxia. — 
Syphilii  of  Special  Nerves,  of  Nerves  of  Special  Sense,  and  Nerves  of  Motion. — 
Syphilis  of  the  Sympathetic. 

SYPHILIS  attacks  the  nervous  system,  as  it  does  all  other  organs,  through 
its  connective  tissue  and  its  blood-vessels.  There  is  a  constructive  form 
which  does  not  soften,  but  contracts  after  its  formation,  and  by  pinching 
the  delicate  nervous  cells  and  tubes  gives  rise  to  the  most  varied  symp- 
toms. There  is  also  the  gummatous  destructive  form  of  disease,  which 
destroys  all  the  tissues  implicated  by  softening  or  cheesy  metamorphosis, 
and  by  its  own  pressure  occasions  numerous  symptoms. 

The  brain,  the  cord,  and  the  nerves  are  also  exposed  to  injury,  on  ac- 
count of  pathological  processes  occurring  in  surrounding  structures.  The 
meninges  of  the  brain  and  cord  are  liable  to  inflammatory  thickening  and 
to  gummatous  deposits,  the  bones  of  the  cranium  and  of  the  spinal  column 
may  be  the  seat  of  necrosis  or  caries,  nodes  may  grow  upon  the  bones 
and  press  upon  the  delicate  nervous  structures  within.  The  nerves,  as 
they  leave  the  great  centres,  are  exposed  to  pinching  by  a  syphilitic 
thickening  of  the  bony  channels  through  which  they  escape,  and  after 
they  are  among  the  tissues  by  interstitial  syphilitic  lesions  within  their 
sheaths  (gummata),  and  by  implication  in  other  syphilitic  processes  along 
their  track  (gummata,  pressure  by  nodes,  etc.). 

Finally,  a  large  number  of  symptoms  of  brain  disease,  which  formerly 
•were  seemingly  beyond  the  possibility  of  explanation,  are  now  found  to 
be  due  to  changes  in  the  walls  of  the  arteries  supplying  the  brain.  This 
has  been  made  very  clear  of  late,  by  the  admirable  treatise  of  Heubner,1 
and  the  researches  of  other  observers  who  have  followed  him.  Apoplexies, 
blood-cysts,  occlusion  of  arteries,  and  consequent  softening  of  portions  of 
the  brain,  or  at  least  interruption  of  the  function  of  such  parts,  may  all  be 
explained  easily  by  the  arterial  lesions.  No  greater  step  toward  the  com- 
prehension of  the  effects  of  syphilis  has  been  made  for  many  years  than 
this  one  of  the  recognition  of  the  possible  result  of  syphilis  upon  the 
arteries,  and  the  consequent  interference  of  function  in  the  tissues  whose 
blood-supply  has  been  thus  cut  off  or  lessened. 

1  Die  Luetische  Erkrankung  der  Hirnarterien.     Leipzig,  1874. 


206  THE    VENEREAL   DISEASES. 

The  sympathetic  ganglia  are  also  exposed  to  injury  by  changes  anal- 
ogous to  those  which  affect  the  brain. 


SY.PHILIS    OF   THE    BRAIN. 

Changes  in  the  bones  surrounding  the  brain  may  occasion  ner- 
vous symptoms.  Such  changes  commonly  are  nodes  from  the  inner  table, 
and  necrosis  (involving  the  meninges  in  inflammatory  disturbance). 
Thickening  of  the  periosteum  or  disease  of  the  bone,  about  any  of  the 
foramina  through  which  the  cranial  nerves  find  exit,  leads  to  loss  or  im- 
pairment of  the  function  of  that  nerve. 

The  meningeal  lesions  are  pachymeningitis  and  gummatous  deposits. 

Pachymeningitis. — This  is  a  connective-tissue  cellular  proliferation 
going  on  to  organization  into  fibrous  thickening  of  the  tissues  involved.  It 
generally  occurs  over  the  anterior  lobes  of  the  cerebrum,  on  the  convex 
surface,  or  at  the  base.  The  dura  mater  is  most  often  involved,  the  pia  ma- 
ter next,  the  arachnoid  least  often.  There  may  be  disseminated  patches  of 
disease,  or  a  large  area  may  be  generally  implicated.  When  the  pia  mater 
is  involved,  the  arachnoidal  surfaces  may  adhere,  and  the  underlying  brain 
surface  be  included  in  a  uniform  sclerosis,  the  thickened,  tough  membranes 
being  adherent  to  the  brain,  so  that  the}'  cannot  be  lifted  without  lacer- 
ating the  surface  of  the  latter. 

Gummatous  deposits  in  the  meninges  are  found  as  scattered,  yellow, 
softened  or  cheesy  nodules,  amidst  the  sclerosed  patches  of  pachymenin- 
gitis, or  spread  out  in  yellow  layers  between  the  thickened  meninges,  or 
in  the  shape  of  distinct  tumors  between  the  dura  mater  and  the  bone,  in 
the  substance  of  the  membranes,  or  on  the  surface  of  the  brain.  Such 
tumors,  at  first  cellular,  gray  and  soft,  become  gelatinous,  with  fibrous 
envelopes,  then  fibro-granular,  finally  cheesy. 

The  lesions  of  the  brain-substance  are:  a  diffuse  encephalitis,  a  white 
softening,  gummata. 

Encephalitis  is  a  new  cellular  formation  in  the  delicate  connective 
tissue  of  the  brain,  and  along  the  vessels.  Like  the  same  process  else- 
where, it  finally  goes  on  to  form  a  sclerosed  patch  pinching  the  tender 
nerve-elements. 

White  softening  occurs  over  a  limited  area,  which  may  have  become 
deprived  of  its  blood  by  the  obliteration  of  the  artery  supplying  it,  on  ac- 
count of  syphilitic  deposits  in  its  walls. 

Gumma  of  the  brain  forms  in  the  outer  coat  of  the  small  arteries, 
and  spreads  from  thence.  Gummata  are  not  common  in  the  brain-sub- 
stance, and  when  found,  it  is  most  often  in  the  cerebrum  near  the  surface. 
The  tumors  exist  as  fibrous  masses  with  cheesy  centre,  or  as  a  soft  accumu- 
lation surrounded  by  a  wall  of  condensed  connective  tissue;  occasionally 
the  contents  are  absorbed  and  a  cyst  remains.  The  whole  gumma  may 
be  absorbed,  leaving  a  fibrous  cicatrix. 


SYPHILIS    OP   THE    CEREBRAL    ARTERIES. 

Heubner's  monograph  on  syphilis  of  the  cerebral  arteries  has  called 
attention  to  the  frequency  of  this  lesion  in  syphilis,  and  explained  many 
of  the  cases  which  formerly  had  to  be  ranked  as  nervous  syphilis  sine 
materia,  because  no  lesion  could  be  found.  Doubtless  there  is  a  nervous 


SYPHILIS    OF   THE   NERVOUS    SYSTEM.'  207 

syphilis  sine  materia.  The  analgesia  and  anaesthesia  of  secondary  syphilis, 
and  some  of  the  paralytic  attacks  coming  on  a  few  months  after  chancre, 
are  doubtless  due  to  the  direct  effect  of  the  poison,  or  to  irregularities  in 
the  circulation  of  the  nerve-centres,  dependent  essentially  upon  the  in- 
fluence of  the  poison  of  syphilis,  without  tissue-change.  Analogous  phe- 
nomena occur  in  nervous  gout.  It  is  not  well,  however,  to  make  any  di- 
vision of  a  set  of  symptoms,  under  the  head  of  nervous  syphilis  without 
physical  lesion,  because  the  classification  tends  to  encourage  negligence  in 
pathological  diagnosis.  Very  possibly  lesions  will  be  eventually  found  to 
cover  all  cases,  since  the  arterial  lesions  already  account  for  many  nervous 
syphilitic  troubles,  formerly  incomprehensible,  so  far  as  their  pathology 
was  concerned. 

The  customary  lesion  of  the  arteries  produced  by  syphilis  is,  according 
to  Heubner,  an  endo-arteritis  commencing  as  a  round-celled  deposit  in  the 
intima  between  the  endothelium  and  the  membrana  fenestra.  The  growth 
of  these  cells  forms  a  lumpy  swelling,  which  diminishes  the  calibre  of  the 
artery.  Later  on,  all  the  coats  of  the  vessel  become  the  seat  of  a  round- 
celled  infiltration. 

As  a  result  of  these  changes,  the  proximal  side  of  the  vessel  is  apt  to 
become  dilated,  rupture,  and  hemorrhage  may  occur  or  thrombus  may  form 
at  the  constricted  spot.  Atrophy  of  the  normal  elements  of  the  vessel- 
wall  results  from  the  presence  of-  the  new  growth.  Spontaneous  cure 
occurs  by  obliteration  of  the  vessel. 

The  carotid  arteries  and  their  branches  are  more  often  involved  in  this 
process  than  the  basilar.  Syphilitic  arteritis  is  always  a  late  lesion.  Heub- 
ner only  encountered  it  once  within  six  months  of  chancre;  and  in  this 
case  it  seemed  quite  probable  that  the  patient's  syphilis  had  antedated  his 
supposed  chancre  by  several  years. 

Symptoms  of  brain  syphilis. — Symptoms  of  the  most  varied  char- 
acter are  produced  by  syphilis  of  the  brain — symptoms  involving  the  in- 
tellect and  all  of  the  functions  of  the  body,  symptoms  simulating  a  variety 
of  cerebral  diseases. 

Headache  is  a  prominent  symptom  in  all  stages  of  syphilis.  Early  in 
the  disease  it  may  be  neuralgic,  or  due  to  anaemia  or  hyperaemia.  Later 
it  implies  lesions  of  the  bones  of  the  cranium,  or  gummatous  processes,  or 
pachymeningitis.  It  is  generally  intense  in  all  stages  of  the  disease,  and 
worse  at  night. 

Vertigo  early  in  syphilis  is  believed  to  be  due  to  congestive  or  anaemic 
conditions  of  the  brain;  later  to  material  lesions  of  all  sorts,  particularly 
arterial  degenerations. 

Convulsive  seizures,  especially  unilateral  spasm  (Jackson),  epilepsy, 
vomiting,  photophobia,  strabismus,  varied  lesions  of  the  eye,  dementia, 
weakness,  loss  of  consciousness — all  these  are  symptoms  apt  to  be  con- 
nected with  peripheral  lesions,  pachymeningitis,  and  gummatous  processes 
near  the  surface  of  the  cerebrum  or  cerebellum,  or  at  the  base  of  the 
brain. 

Gummata  of  any  size  are  apt  to  produce  symptoms  similar  to  those 
k  due  to  other  cerebral  tumors  similarly  situated. 

Encephalitis  may  give  rise  to  disturbance  of  the  intellect,  mania,  in- 
sanity, paralysis,  epilepsy  without  aura,  convulsions  without  unconscious- 
ness, often  slow  in  coming  on. 

Arterial  lesions  may  occasion  aphasia,  hemiplegia,  and  troubles  of  the 
intelligence. 

Death  from  syphilitic  brain  trouble  may  be  the  result  of  the  bursting 


208  THE    VENEREAL    DISEASES. 

of  a  vessel,  gradually  progressive  enfeeblement  and  cachexia;  to  wast- 
ing of  the  nerve-force  or  to  encaphalitis. 

The  symptoms  of  syphilis  are  greatly  varied,  and  are  not  proportionate 
to  the  extent  of  the  lesion  or  to  its  situation.  Frightful  attacks  of  nerv- 
ous symptoms  terminating  life  sometimes  reveal  nothing  to  the  patholo- 
gist more  serious  than  arterial  lesions;  while,  on  the  other  hand,  tumors 
and  extensive  meningeal  troubles  connected  with  lesions  of  bone  are 
found  after  death,  when  there  has  been  little  more  than  local  pain  during 
life  to  direct  the  physician's  attention  to  the  brain.  Occasionally,  serious 
lesions 'are  found  attended  by  symptoms  during  life,  where  there  has  been 
no  complaint  of  pain. 

Indeed,  syphilis  is  picturesque  and  irregular  in  its  nervous  expressions, 
as  well  as  in  its  other  symptoms;  and  it  is  often,  by  this  very  quality  of 
irregularity  in  the  grouping  of  the  nervous  symptoms,  that  a  diagnosis  of 
syphilitic  brain  disease  can  be  made. 

Certain  groupings  of  symptoms  are  believed  to  be  pathognomonic  of 
syphilis.  One  of  these  is  unilateral  spasm  commencing  in  the  fingers  or 
thumb,  running  up  one  limb  and  down  the  other,  without  unconscious- 
ness, sometimes  terminating  in  a  general  convulsion  with  loss  of  conscious- 
ness (Jackson).  Speech  may  or  may  not  be  involved,  and  partial  paraly- 
sis may  or  may  not  follow  on  the  side  which  was  the  seat  of  the  hemi- 
spasm. 

Optic  neuritis  and  mydriasis  very  often  attend  syphilitic  nervous  symp- 
toms due  to  syphilis. 

Balfour1  calls  attention  to  the  fact  that  a  coexistence  of  facial  neu- 
ralgia, with  paralysis  of  any  of  the  nerves  going  to  the  muscles  of  the  eye, 
forms  strong  presumptive  evidence  of  cerebral  syphilis,  since  the  cavernous 
sinus,  the  only  point  where  these  different  nerves  run  near  each  other,  is 
a  favorite  seat  of  syphilitic  deposit. 

In  general,  an  irregular  grouping  of  nervous  symptoms  is  suggestive 
of  syphilis,  such  as  paralysis  of  a  group  of  muscles  of  one  arm  and  the 
leg  of  the  opposite  side,  coinciding  with  mydriasis  or  optic  neuritis.  The 
explanation  of  this  is  that  the  lesions  of  syphilis  are  scattered  and  varied, 
all  tissues  are  liable  to  suffer  from  its  influence,  and  many  of  them  at  the 
same  time. 

The  mental  disturbances  of  syphilis  are  very  varied.  Certain  qualities 
of  mental  derangement  in  connection  with  physical  (paralytic)  symptoms 
are  so  often  encountered  together  as  to  have  in  them  something  almost 
clinically  pathognomonic.  There  is  a  certain  quality  of  brain-weariness 
which  is  constantly  complained  of.  The  patient  cannot  fix  his  mind  upon 
anything  intently;  his  brain  gets  tired  at  once.  Sometimes  he  cannot 
even  read  a  newspaper,  he  cannot  cipher,  often  he  cannot  write  a  letter, 
while  he  can  talk  and  laugh  as  well  as  ever,  and  to  a  careless  observer 
does  not  appear  to  be  at  all  deficient  in  brain-power. 

There  is  also,  generally,  a  tendency  to  emotional  excess  in  patients 
whose  brains  are  weakened  by  the  physical  lesions  of  syphilis.  Such  in- 
dividuals will  laugh  or  cry  at  the  very  slightest  provocation,  they  get 
gloomy  and  frightfully  depressed  sometimes  without  cause,  while  other 
patients  seem  to  be  made  careless  and  happy  by  their  malady,  their  whole 
character  being  changed.  This  latter  result  is  less  common  than  the 
others. 

Finally,  there  is  a  hebetude,  a  dementia  quite  common  in  connection 

1  Edin.  Med.  Jour.,  Oct.,  1875,  p.  289. 


SYPHILIS    OF   TIIE    NERVOUS    SYSTEM.  209 

with  advanced  brain  lesions  due  to  syphilis.  The  patient  will  exhibit  a 
slowness  of  apprehension  which  is  phenomenal.  He  will  be  painfully 
slow  in  grasping  ideas  which  are  presented  to  him,  and  equally  deliber- 
ate  in  expressing  his  own  ideas  in  reply.  Such  patients  look  blank  and 
stupid  in  the  face.  The  muscles  of  expression  seem  to  be  powerless.  A 
stupid,  dull  stare  greets  the  inquirer  in  response  to  every  idea  presented 
to  the  patient.  In  these  cases  the  patient,  who  is  perhaps  paralyzed 
on  one  side,  will  sit  with  his  mouth  open  and  saliva  dribbling  upon  his 
coat,  until  he  is  told  to  shut  his  mouth,  when  he  will  slowly  and  stupidly 
obey.  He  will  leave  food  in  his  mouth  uiimasticated,  seeming  to  forget 
it,  and  yet  may  retain  his  reasoning  powers,  his  speech,  and  all  his  intel- 
ligence— much  blunted,  of  course,  but  not  absent. 

When  any  of  these  three  varieties  of  intelligential  variation,  emotional 
excess,  brain-weariness,  hebetude,  coincide  with  mydriasis,  localized  mus- 
cular paralysis,  and  tender  shins,  syphilis  may  be  predicated  as  a  cause  of 
these  phenomena,  with  nearly  absolute  certainty  of  making  a  correct  di- 
agnosis. Pain  in  the  head,  worse  at  night,  makes  the  diagnosis  more  cer- 
tain, and  improvement  under  antisyphilitic  treatment  removes  any  lin- 
gering doubt  which  may  have  arisen  from  failure  to  find  physical  evidences 
of  past  syphilis,  or  a  history  of  the  disease. 

The  prognosis  of  the  nervous  symptoms  of  syphilis  is  always  rela- 
tively good.  That  is,  no  matter  what,  or  how  severe,  or  how  extensive, 
or  how  long  standing  the  symptom,  there  is,  as  a  rule,  more  hope  of 
effecting  its  cure,  if  syphilis  can  be  made  out  to  be  its  cause,  than  if  it 
originated  from  any  other  malady.  Apparently  hopeless  cases  of  the 
most  profound  coma,  symptoms  resembling  brain-softening  in  all  respects, 
paralyses  of  the  most  varied  kinds,  blindness  and  deafness,  furious 
epilepsy,  violent  mania,  insanity,  general  paralysis,  dementia — none  of 
these  conditions  in  their  worst  form  involve  more  than  a  reserve  in  their 
prognosis,  if  syphilis  is  their  cause.  Many  cases,  which,  on  account  of  their 
long  standing,  cannot  be  perfectly  cured,  are  yet  capable  of  vast  improve- 
ment, by  the  judiciously  vigorous  employment  of  an  active  anti-syphilitic 
medication,  including  a  trial  of  the  iodides  pushed  unsparingly. 

As  to  the  liability  of  occurrence  of  nervous  symptoms  due  to  syphilis 
in  a  given  case  of  the  disease,  it  is  impossible  to  speak  with  much  assur- 
ance. There  is  a  general  impression  which  Broadbent '  has  formulated, 
citing  Gros  and  Lancereaux,  Braus,  Buzzard  and  Moxon,  as  corroborating 
his  opinion,  that  it  is  chiefly  when  secondary  symptoms  are  light,  or 
when  tertiary  symptoms  come  on  very  early,  that  symptoms  due  to  lesions 
of  nerve-tissue  are  to  be  feared.  There  is  some  foundation  for  this, 
doubtless,  but  it  is  far  from  being  a  rule.  Many  cases  are  very  light  at 
first,  and  very  severe  at  the  end;  others  seem  to  extend  their  violence  in 
the  cutaneous  outbreaks  of  the  first  eighteen  months  of  the  disease,  and 
then  cease  entirely;  but  an  absolute  rule  is  very  impossible  in  this,  as  in 
most  other  general  questions  regarding  syphilis. 

Syphilis  acts  differently,  according  to  the  physical  predisposition  and 
the  constitution  of  the  person  who  suffers  from  it.  Gouty  and  rheumatic 
patients,  and  those  with  general  nervous  tendencies,  certainly  are  more 
apt  to  suffer  from  brain  syphilis  than  others,  and  these  patients  are 
just  the  ones  who  habitually  have  light,  but  protracted  attacks  of 
superficial  papulo-squamous  lesions  throughout  the  existence  of  their 
malady.  It  is  not  because  they  have  light  early  syphilis,  that  Tater  on 

1  Lancet  1874,  1  nos.,  2-6. 
14 


210  THE    VENEREAL    DISEASES. 

they  get  brain  disease,  but  both  the  results  arise  from  one  and  the  same 
predisposing  constitutional  cause,  and  not  at  all  from  any  peculiarity  in 
the  quality  of  the  syphilitic  virus  which  they  have  absorbed,  or  its  quan- 
tity. Such  patients  are  apt  to  have  more  pains  and  neuralgic  symp- 
toms early  in  their  attacks,  than  others  ;  headache,  side-ache,  bone-ache, 
anaesthesia,  analgesia,  vertigo,  etc. 

Treatment. — The  general  treatment  of  nervous  syphilis  keeps  in 
view  the  delicate  nature  of  the  structures  which  are  threatened.  The 
gummatous  exudation  which  is  pressing  upon  nerve  cells  and  fibres  must 
be  speedily  removed  at  any  cost,  the  congested  periosteum  must  be  re- 
strained in  its  tendency  to  construct  a  bony  node,  or  to  thicken  into  an 
irritative  patch  upon  the  cerebral  surface,  the  thickening  in  the  arterial 
wall  must  be  arrested  before  it  closes  the  calibre  of  the  vessel — or  delicate 
nerve-tissue  will  be  destroyed,  which  no  human  power  can  restore.  Con- 
sequently, great  vigor  is  called  for  in  the  employment  of  the  means  we 
have  at  hand,  and  great  judgment  and  care  in  the  management  of  all  the 
surroundings  of  the  patient,  his  diet,  his  habits,  his  hygiene. 

The  light  congestive  lesions  which  give  symptoms  early  in  syphilis  get 
well  on  mercury  alone;  those  of  the  later  variety  require  large  doses  of 
the  iodides  often,  preferably  combined  with  the  mercurials. 

Refinements  in  diagnosis,  however,  are  not  always  possible,  or  proper, 
in  face  of  probable  grave  lesions  threatening  important  functions  ;  and  it 
is  better  in  all  cases  of  serious  nervous  disease  due  to  syphilis  to  employ 
both  the  mercury  and  the  iodides,  and  to  push  them  both  boldly  until  the 
symptoms  yield.  Mercury  should  be  given  by  the  vapor-bath  or  by  inunc- 
tion, the  stomach  being  reserved  for  the  iodides.  The  latter  should  be 
used  without  stint,  commencing  at  a  gr.  x.  or  gr.  xx.  dose,  according  to 
the  severity  of  the  symptoms  and  the  date  of  the  attack  from  chancre, 
and  increasing  rapidly  up  to  the  point  of  tolerance,  using  all  precautions 
to  protect  the  stomach  (p.  134). 

After  the  symptoms  have  yielded,  treatment  should  be  continued  for 
a  long  time,  and  then  be  slowly  dropped,  tapering  off  the  course  of  the 
iodides,  and  continuing  with  the  mercurials,  watching  the  patient  for  any 
evidences  of  possible  relapse. 


THE    SPECIAL    AFFECTIONS     PRODUCED     BY    SYPHILITIC     LESIONS     OF     THE 

BRA1X. 

A  few  words,  setting  forth  some  of  the  peculiar  qualities  which  attach 
to  certain  affections  of  the  nervous  system  when  due  to  syphilis,  will  make 
it  easier  to  differentiate  them  from  analogous  affections  dependent  upon 
morbid  processes,  the  nature  of  which  is  not  syphilitic. 


SYPHILITIC    HEMIPLEGIA. 

Hemiplegia  due  to  syphilis  is  usually  observed  in  patients  who  are 
comparatively  young,  since  it  generally  occurs  within  a  few  years  of 
chancre,  and-  chancre  is  more  often  acquired  by  the  young  than  by  the 
old.  It  has  been  observed  quite  early  in  syphilis.  Taylor  '  reports  a  case 

1  Journal  of  Nervous  and  Mental  Diseases,  January,  1876,  p.  20. 


SYPHILIS    OP   THE    NERVOUS    SYSTEM.  211 

in  the  fifth  month  from  chancre,  but  it  is  more  common  after  several  years. 
There  are  three  varieties  of  attack  : 

1.  Sudden  loss  of  motion  in  one  side  without  any  previous  warning1, 
excepting,  perhaps,  persistent  pain  in  the  head,  worse  at  night.     In  con- 
nection with  Professor  Van  Buren,  I  have  reported  a  number  of  instances 
of  this  variety  of  attack.1     Under  these  circumstances  there  is  commonly 
no  loss  of  consciousness  with  the  paralytic  stroke. 

2.  Hemiplegia  may  come  on  very  slowly,  taking  perhaps  several  weeks 
to  beome  complete.     The  face  may  become  paralyzed,  and  then,  gradu- 
ally, the  upper  extremity.     Finally,  the  loss  of  power  extends  to  the  thigh 
and  leg,  or  the  lower  extremity  may  be  spared  altogether.     In  this  form 
also  there  is  no  loss  of  consciousness  with  the  attack. 

Finally,  3,  hemiplegia  may  be  due  to  syphilitic  degeneration  of  an  ar- 
tery which,  thinned  by  gummatous  deposit,  or  dilated  behind  an  obstruc- 
tion, may  give  way  and  occasion  true  apoplexy.  This  form  of  syphilitic 
hemiplegia  may  be  attended  by  loss  of  consciousness,  like  ordinary  apo- 
plexy. 

Headache  localized  in  one  spot  very  often  precedes  the  seizure  by  sev- 
eral weeks.  The  intensity  of  this  headache  is  sometimes  extreme,  parti- 
cularly at  night  ;  and  if  the  lesion  be  peripheral,  pressure  upon  the  bone 
over  it  increases  the  pain. 

Of  the  hemiplegia  itself,  it  may  be  partial  or  complete.  Motion  and 
sensibility  may  both  be  abolished,  but  sensibility  is  commonly  less  im- 
paired than  motion.  Sometimes  one  side  is  paralyzed  in  its  sensibility 
alone,  motion  being  normal.  Hemispasm  of  the  affected  side  may  pre- 
cede the  paralysis.  Several  mild  attacks  of  hemiplegia  may  follow  each 
other  at  short  intervals,  and,  finally,  be  succeeded  by  a  full  attack,  which 
remains  permanent. 

Other  general  nervous  symptoms,  intelligential  or  emotional,  such  as 
have  been  described  (p.  208),  generally  accompany  syphilitic  hemiplegia; 
but  upon  this  point  there  is  no  certain  rule. 

I  have  seen  one  case  of  partial  syphilitic  hemiplegia  in  a  young  girl 
with  inherited  disease. 

Early  treatment  is  sometimes  followed  by  rapid  and  complete  cure. 


SYPHILITIC   EPILEPSY. 

Epilepsy  generally  comes  on  several  years  after  chancre.  Bumstead 
has  observed  a  case  within  a  few  months  from  the  primary  lesion,  and 
Althaus *  has  reported  a  case  in  a  child  with  inherited  disease.  The  con- 
vulsive attacks  in  this  affection  are  not  exactly  like  those  of  true  epilepsy, 
and  the  patient  is  generally  a  grown  man,  instead  of  a  youth,  as  he  com- 
monly is  in  true  epilepsy.  The  convulsion  in  syphilitic  epilepsy  is  rarely 
preceded  by  an  aura.  It  nearly  always  commences  in  unilateral  spasm. 
There  are  night  and  day  attacks,  as  in  true  epilepsy,  and,  in  syphilis,  a 
tendency  to  an  explosion,  as  it  were,  a  number  of  attacks  occurring  in 
rapid  succession,  followed  by  a  considerable  interval  of  calm.  This  pecu- 
liarity, however,  is  also  noticed  in  true  epilepsy.  In  syphilitic  epilepsy, 
as  in  the  ordinary  form,  there  occur  the  half  attacks,  as  well  as  the  full 
attacks ;  but  the  former  are  not  so  much  confined  to  the  head  as  in  true 

1  Syphilis  of  the  Nervous  System :  N.  Y.  Med.  Journ.,  Nov.,  1870. 
1  Med.  Times  and  Gaz.,  April,  1874,  p.  389. 


212  THE    VENEREAL    DISEASES. 

epilepsy  ;  there  may  be  only  a  partial  unilateral  spasm,  passing  away  with- 
out reaching  the  extent  of  a  full  attack. 

The  features  which  are  commonly  relied  upon  to  diagnosticate  syphi- 
litic epilepsy  (besides  the  history)  are:  the  relatively  advanced  age  of  the 
patient;  the  existence  of  persistent,  fixed  headache  before  the  attack, 
worse  at  night;  a  persistence  or  aggravation  of  the  intellectual  symptoms 
(hebetude,  etc.)  between  the  attacks,  instead  of  a  diminution  of  the  same, 
such  as  is  encountered  in  ordinary  epilepsy;  and  the  peculiar  character  of 
the  attack,  commencing  perhaps  habitually  in  a  thumb  or  finger,  and  be- 
coming first  unilateral,  then  general. 

Special  paralysis  of  the  cerebral  nerves  is  less  often  observed  with 
syphilitic  epilepsy  than  with  some  of  the  other  forms  of  nervous  syphilis. 
Fatal  cases  generally  terminate  with  profound  coma,  more  or  less  pro- 
longed. 

OTHEK   POEMS   OF   HERVOT7S    SYPHILIS    AFFECTING   THE   MUSCLES. 

Generalized  paralysis,  closely  simulating  the  generalized  paralysis  of 
the  insane,  is  not  a  very  infrequent  symptom  of  brain  syphilis.  There  is 
no  constant  lesion  found  in  this  condition.  The  patient  is  more  apt  to  be 
depressed  and  to  suffer  from  hebetude  than  to  entertain  ideas  of  grandeur, 
as  in  non-specific  general  paralysis.  Catalepsy  of  syphilitic  origin  has 
been  encountered,  and  even  chorea;  but  these  affections  are  not  well  de- 
fined, and  are  very  rare.  All  of  these  maladies,  when  due  to  syphilis,  re- 
spond to  a  well-directed,  vigorous  treatment.  A  cure  may  not  be  possi- 
ble in  all  of  them,  but  much  improvement  can  generally  be  attained. 


SYPHILITIC    APHASIA. 

This  affection  is  by  no  means  uncommon  as  a  result  of  syphilis  of  the 
brain.  It  may  come  on  quite  early  in  the  disease,  but,  like  the  other 
nervous  affections,  is  generally  quite  late.  All  the  forms  exist,  due  to  syphi- 
lis— the  loss  of  articulate  speech  with  ability  to  write,  loss  of  speech  as 
well  as  of  the  power  of  writing,  the  use  of  words  inappropriately,  the  loss 
of  one  language  while  another  is  remembered  when  the  patient  could  talk 
in  two  tongues.  The  prognosis  is  better  in  syphilitic  aphasia  than  in  any 
other  form,  but  there  is  nothing  in  the  affection  itself  which  stamps  its 
syphilitic  nature  upon  it.  History  and  concomitant  signs  must  be  relied 
upon  for  a  diagnosis.  Treatment  commenced  promptly  is  often  very 
effective. 

SYPHILITIC    INSANITY. 

Mania,  acute  and  chronic,  hebetude,  dementia,  and  general  paralysis  are 
certainly  in  some  cases  due  to  syphilis.  History,  accompanying  phenom- 
ena, and  other  symptoms  affecting  the  nervous  system  due  to  syphilis, 
have  to  be  relied  upon  for  a  diagnosis.  The  whole  matter  is  clothed  in 
considerable  uncertainty;  but,  where  there  can  be  any  certainty  of  the  ex- 
istence of  syphilis,  no  consideration  should  deter  the  physician  from  giving 
the  patient  the  benefit  of  the  doubt.  The  effect  of  treatment  is  often  very 
prompt  in  these  cases,  and  lifts  the  cloud  from  the  patient's  brain,  an 
effect  as  apparent  to  the  sufferer  and  his  friends  as  it  is  to  his  physician. 
1  have  known  a  case  of  profound  coma  where  there  was  no  positive 


SYPHILIS    OF   THE   NERVOUS    SYSTEM.  213 

history  of  previous  disease,  and  where  the  patient  could  give  no  account 
of  himself,  yet  where  a  diagnosis  of  brain  syphilis  was  made  and  acted 
upon,  to  the  prompt  relief  of  the  patient.  In  such  cases  it  is  well  to  search 
the  whole  body  of  the  patient.  Look  for  circular  white  scars  with  a  pig- 
mented  margin,  examine  the  pupils  for  mydriasis.  Search  the  retina  with 
the  ophthalmoscope  for  optic  neuritis.  Pinch  the  shins,  even  if  no  nodes 
are  found,  and  see  if  the  patient  shrinks.  Press  upon  all  the  different 
parts  of  the  skull,  and  notice  whether  the  patient  moves,  as  if  he  disliked 
pressure  upon  any  particular  spot.  Finally,  examine  the  throat  for  cica- 
trices of  past  syphilitic  lesions,  and  frequently,  without  asking  a  question, 
a  diagnosis  of  nervous  syphilis  can  be  made,  and  a  treatment  instituted 
which  will  restore  the  patient  promptly  to  the  exercise  of  his  functions. 


BEAIK   SYPHILIS   SIMULATING   SUNSTROKE. 

Desire  to  sleep  is  often  a  marked  symptom  in  the  case  of  patients 
with  brain  syphilis.  It  may  be  connected  with  the  most  varied  symp- 
toms, or  occur  independently  of  other  symptoms  of  a  nervous  order.  It 
is  most  apt  to  come  on  after  an  attack  of  supposed  sunstroke. 

Patients  in  late  syphilis  not  infrequently  first  show  nervous  trouble  in 
the  following  way:  on  a  hot  day,  while  under  exertion,  or,  sometimes, 
when  doing  nothing,  such  a  patient  will  be  overpowered  with  the  heat, 
as  it  is  called.  There  will  be  faintness,  vertigo,  pain  in  the  head,  perhaps 
loss  of  consciousness.  These  symptoms  are  apt  to  be  followed  by  loss  of 
strength,  inability  to  undergo  physical  exertion,  positive  incapacity  for 
any  mental  effort,  and  with  this,  often  a  languid  condition  of  general 
incapacity  and  inability  to  do  anything,  which  is  very  distressing  to  the 
patient.  With  this,  sometimes,  there  comes  an  intense  desire  to  sleep. 
The  sleep  does  not  satisfy.  With  much  sleep,  the  patient  is  no  better; 
and  with  little  sleep,  not  materially  worse.  Such  patients  often  eat  very 
well — exceptionally  well.  They  grow  fat,  but  cannot  seem  to  get  any 
good  out  of  their  food  in  the  way  of  strength.  Heat,  especially  the  heat 
of  the  sun,  makes  them  worse.  They  feel  better  in  winter,  but  the  sum- 
mer wilts  them  down,  makes  them  good  for  nothing. 

These  patients  do  not  generally  associate  their  symptoms  in  any  way 
with  their  antecedent  syphilis — perhaps  long  forgotten — but  consider 
that  they  have  been  "  touched  by  the  sun,"  as  they  often  put  it,  and  they 
seek  for  comfort  through  years  of  tonics  and  electricity,  but  do  not  find 
it.  A  mixed  treatment  of  mercury  and  the  iodides  is  the  best  tonic  for 
these  cases;  but  they  often  drag  along  very  slowly,  and  in  the  end  re- 
main more  or  less  intellectually  and  physically  broken,  and  emotionally 
weak  for  the  remainder  of  their  lives.  Zittman's  decoction  sometimes 
freshens  up  such  cases  amazingly,  or  a  course  at  a  water-cure,  or  at  the 
dry  cure  in  Lindeweisse. 


SYPHILIS    OF   THE    CORD. 

The  lesions  of  syphilis  affecting  the  cord  are  much  the  same  as  those 
which  have  already  been  detailed  in  connection  with  syphilis  of  the 
brain.  The  bones  of  the  spinal  column  suffer  from  exostoses  and  necro- 
sis, its  fibrous  and  vascular  membranes  become  involved  in  pachymenin- 
gitis,  or  the  seat  of  gummatous  deposits,  in  a  diffused  or  circumscribed 


214  THE    VENEREAL    DISEASES. 

form.  The  cord  itself  may  become  soft  in  spots,  or,  more  often,  sclerosed, 
in  connection  with  diffuse,  hyperplastic,  connective-tissue  proliferation, 
or  gummatous  deposits,  or  arterial  changes. 

The  symptoms  attending  all  these  lesions  vary  with  the  locality  and 
extent  of  the  latter.  The  diagnosis  is  generally  obscure,  and  depends 
much  upon  the  history  of  the  concomitance  of  other  symptoms — nervous 
or  otherwise — of  syphilis.  The  treatment  is  often  so  effective  as  to  un- 
expectedly bring  about  a  cure  in  the  most  seemingly  desperate  cases — a 
fact  which  makes  the  prognosis  of  syphilitic  affections  of  the  cord  rela- 
tively very  good. 

The  symptoms  of  syphilis  of  the  cord  are,  loss  of  motion  or  sensation 
in  the  arm,  leg,  or  body,  along  the  course  of  certain  nerves,  the  roots  of 
which  may  be  involved  in  the  lesions,  neuralgias — sometimes  very  in- 
tense, and  worse  at  night — paraplegia,  and  a  spurious  form  of  locomotor 
ataxia. 

SYPHILITIC   PARAPLEGIA. 

Paraplegia  due  to  syphilis  is  rarely  complete.  Occasionally  coming 
on  within  the  first  year  after  chancre,  it  is  usually  one  of  the  very  latest 
of  the  nervous  manifestations  of  syphilis.  It  has  been  encountered  in  in- 
herited disease.  It  often  comes  on  insidiously.  The  patient  notices  that 
his  legs  are  heavier  than  usual.  He  stumbles  more  often  and  on  less  oc- 
casion than  is  his  wont.  He  gets  tired  without  due  cause.  He  drags  his 
feet  more  than  usual.  The  bladder  always  suffers  along  with  the  muscles 
of  the  thighs,  and  legs,  and  the  rectum,  usually,  as  well.  The  patient  can- 
not throw  a  good  stream  of  urine,  and  cannot  extrude  his  fasces  with  any 
satisfaction  to  himself. 

At  this  stage  most  cases  are  diagnosticated  to  be  reflex  urinary  paral- 
ysis, and  the  bladder  is  often  treated,  the  urethra  slit,  the  prepuce  cut  off, 
in  the  hope  that,  the  supposed  cause  of  reflex  paralysis  being  removed,  the 
patient  will  get  well — a  vain  hope  in  these  cases. 

The  legs  are  generally  unequally  paralyzed,  and  one  of  them  much 
more  than  the  other.  Certain  groups  of  muscles  in  the  different  legs  suf- 
fer, perhaps  symmetrically  on  the  two  sides,  sometimes  not  so.  Generally 
sensibility  remains  intact,  occasionally  it  is  abolished. 

There  is  rarely  any  numbness  in  the  extremities,  or  pain  in  the  back, 
or  convulsive  twitchings;  and  there  are  no  pains  in  the  legs  unless  the  le- 
sion is  confined  to  the  meninges  of  the  cord.  The  sensation  of  constric- 
tion around  the  body  is  not  usually  complained  of.  Indeed,  there  is  no 
pathognomonic  sign  by  which  the  syphilitic  nature  of  a  given  paraplegia 
can  be  even  surmised.  The  history,  the  absence  of  any  cause  other  than 
syphilis,  the  presence  of  other  evidences  of  syphilis  of  the  nervous  system, 
or  of  any  of  the  tissues,  are  important  aids  in  the  differential  diagnosis. 
The  good  effect  of  an  energetic  treatment  is  often  quite  prompt  and  very 
obvious  from  the  first.  Mercury  is  of  more  value,  relatively,  in  treating 
syphilitic  lesions  of  the  cord,  than  in  connection  with  similar  lesions  In  the 
brain.  Inunction,  carried  to  the  extent  of  touching  the  mouth,  is  to  be 
tried,  if  an  ordinary  mixed  treatment  with  preponderance  of  the  iodides, 
has  been  pushed  without  success. 

Old  cases  of  paraplegia,  due  to  syphilis,  do  not  generally  get  entirely 
well  under  any  treatment.  They  improve  to  a  certain  extent,  and  then 
stop.  The  emotional  and  other  accompanying  intelligential  phenomena 
may  cease,  and  the  patient  become  absolutely  well,  while  his  bladder,  rec- 


SYPHILIS    OF   THE    NERVOUS    SYSTEM.  215 

turn,  and  certain  muscles  or  groups  of  muscles  in  the  lower  extremity,  re- 
main permanently  weakened. 

la  one  such  case,  seen  with  Dr.  Van  Buren,  it  was  necessary  to  apply 
an  apparatus,  with  an  arrangement  of  rubber  straps  to  represent  the  ham- 
string muscles,  all  of  which  on  both  sides  were  much  atrophied,  in  order 
to  allow  the  patient  to  walk  erect.  The  bladder  calls  for  attention  so  long 
as  its  function  is  interfered  with  by  the  lesion  causing  syphilitic  paraple- 
gia, and  sometimes  for  the  rest  of  the  patient's  life.  Care  must  be  taken 
to  see  that  the  bladder  empties  itself  properly;  and  should  it  not  do  so, 
the  catheter  must  be  gently  used  and  the  bladder  washed  out  at  stated 
intervals.  It  must  be  remembered  that  the  power  of  the  bladder  to  resist 
the  impressions  produced  upon  it  by  local  violence  is  diminished,  on  ac- 
count of  the  damage  to  its  nerves  by  the  syphilitic  lesion.  Consequently, 
much  more  care  and  gentleness  than  usual  is  necessary  in  the  use  of  the 
catheter,  to  escape  lighting  up  cystitis  of  the  vesical  neck,  a  complication 
which  causes  much  pain  and  the  loss  of  time,  and  perhaps  may  lead  to  an 
inflammation  so  profound  as  to  permanently  thicken  the  lining  membrane 
of  the  bladder  and  leave  it  in  a  state  of  mild  chronic  cystitis,  from  which 
it  never  recovers.  It  is  wiser  to  use  enemata  for  the  rectum  than  to  depend 
upon  cathartics. 

SYPHILITIC  LOCOMOTOE  ATAXIA. 

Syphilis  can  certainly  produce  ataxic  symptoms  in  the  lower  extremi- 
ties. Fournier '  has  collected  a  number  of  cases  of  his  own,  of  Fereol,  and 
others.  Whether  the  ataxic  symptoms,  however,  can  be  called  true  loco- 
motor  ataxia,  is  the  question.  Certainly,  the  symptoms  of  true  locomotor 
ataxia  may  be  so  closely  simulated  that  it  is  impossible  to  say,  clinically, 
that  the  disease  produced  by  syphilis  is  not  locomotor  ataxia,  and  certainly, 
also,  treatment  greatly  improves  these  cases.  I  have  observed  several 
cases  in  which  the  violent  pains  in  the  muscles  were  present,  the  strength 
of  the  muscles  preserved,  and  yet  inco-ordination  of  movement  so  marked 
that  the  patient  could  not  walk  without  difficulty,  and  not  run  at  all. 
Such  patients  walk  in  a  very  stiff,  clumsy  way,  bringing  their  heels  down 
solidly  on  the  floor,  but  yet  very  unsteadily.  They  cannot  stand  on  one 
leg,  cannot  run,  cannot  stand  firmly  with  the  eyes  shut,  can  hardly  walk 
at  all  or  turn  around  with  the  eyes  shut,  cannot  feel  the  grourfd  plainly 
under  their  feet,  or  touch  a  given  object  promptly  with  the  end  of  the 
foot,  when  asked  to  do  so.  I  have  not  investigated  the  tendon  reflex  in 
syphilitic  locomotor  ataxia. 

The  legs,  in  these  cases,  remain  firm  and  strong  muscularly,  although 
the  patient  thinks  they  are  weak,  until  the  contrary  is  proved  by  an  at- 
tempt on  the  part  of  his  physician  to  flex  or  extend  the  leg  in  opposition 
to  the  patient's  will.  The  bladder  in  these  cases  is  always  involved  in  the 
lack  of  power  of  co-ordination  between  the  muscles  which  control  its 
function.  Generally  there  is  no  atony,  the  expulsive  power  is  good,  but 
there  is  more  or  less  persistent  spasmodic  stricture,  the  cut-off  muscles  of 
the  deep  urethra  failing  to  relax  in  response  to  the  patient's  will.  Such 
cases  are  apt  to  become  annoying  and  to  call  for  the  use  of  the  catheter. 
The  bladder  itself  does  not  generally  require  washing  or  other  treatment. 
The  rectum  is  not  generally  interfered  with,  in  its  function,  to  any  marked 
extent. 

1  Gaz.  med.  de  Paris,  December  30,  1876. 


216  THE   VENEREAL    DISEASES. 

I  have  seen  one  case  where  paraplegia  with  wasting  of  the  muscles 
and  great  loss  of  power  in  the  lower  extremities  came  on,  produced  by 
syphilis  of  the  cord.  The  patient  could  not  get  about  without  crutches. 
Under  treatment  he  got  well  of  his  paraplegia,  but  the  sclerosed  patches 
left  in  his  cord  by  the  antecedent  syphilitic  lesions  produced  ataxia.  His 
muscles  increased  in  strength,  his  legs  and  thighs  grew  visibly  in  size, 
he  discarded  his  crutches;  but  presently  he  got  a  sensation  of  constric- 
tion about  the  body,  and  found  that  he  could  not  control  his  legs.  He 
had  to  resume  a  cane,  and  finally  crutches  again,  although  his  legs  and 
thighs  were  now  large  and  firm,  and  no  effort  on  my  part  could  flex  or  ex- 
tend his  leg  against  his  will.  Bladder  symptoms,  which  had  come  on  in 
this  case  with  the  paraplegia,  persisted  during  the  ataxia. 

The  treatment  of  ataxia  due  to  syphilis  is  that  of  tertiary  syphilis — 
mixed  treatment,  with  an  excess  of  iodides.  I  believe,  however,  that  mer- 
cury used  freely  has  more  effect  in  these  cases  than  the  iodides,  and  have 
seen  good  effects  follow  a  vigorous  course  of  inunction. 

The  effect  of  treatment  is  slow  and  often  unsatisfactory  ;  I  think 
more  so  in  ataxic  syphilis  than  in  any  other.  It  may  be  that  the  sclerosis 
causing  ataxia  is  secondary  to  previous  syphilitic  deposits,  and,  being 
pseudo-cicatricial,  is  of  course  permanent  and  not  influenced  by  treatment. 
These  cases  are  so  rare  that  it  is  hard  to  make  deductions  about  them.  I 
have  not  met  more  than  half  a  dozen  cases  in  all.  I  cannot  recall  more 
than  one  reasonably  perfect  cure;  but  all  the  cases  were  improved  by 
treatment. 

SYPHILIS    OF   SPECIAL   NERVES. 

The  gummatous,  bony  and  pachymeningeal  changes,  so  common  at  the 
circumference  of  the  great  nervous  centres,  often  bring  about  symptoms 
referable  to  implication  of  the  different  nerves  dependent  on  pressure  at 
their  points  of  exit  through  the  foramina,  or  implication  along  their  course 
(e.  ff.f  in  the  cavernous  sinus)  in  gummatous  changes.  Hence,  the  disor- 
derly grouping  of  nervous  symptoms  has  been  considered  to  be  sugges- 
tive of  syphilis  as  a  cause  of  all  the  various  phenomena,  since  the  lesions 
of  syphilis  are  apt  to  be  multiple  and  scattered,  without  any  particular 
order  in  their  distribution,  and  it  is  natural  for  the  symptoms  to  partake 
of  the  same  character. 

Again,  the  special  nerves  themselves,  any  of  them,  may  occasionally 
suffer  from  congestive,  hvperplastic  or  gummatous  changes  in  their  con- 
nective tissue,  or  sheaths  at  any  part  of  their  course,  or  be  involved  in 
neighboring  gummatous  processes  or  other  tissue-changes.  In  this  way 
disorderly  symptoms  of  different  nerves  may  come  on,  due  to  syphilis  as 
a  cause. 

Finally,  the  essential  influence  of  the  syphilitic  poison,  without  physi- 
cal lesion,  doubtless  occasions  some  nervous  symptoms,  especially  early 
in  the  disease,  such  as  neuralgias,  inordinate  appetite,  sciatica,  local  areas 
of  analgesia  and  anaesthesia  at  the  backs  of  the  hands  and  elsewhere. 

Heubner '  states  that  it  is  unusual  for  any  of  the  special  nerves  to  be 
involved  when  the  nervous  symptoms  are  due  to  lesions  of  the  cerebral 
arteries  (syphilitic  endo-arteritis). 

No  nerve  in  the  body  is  free  from  the  possibility  of  being  attacked  by 
syphilis,  but  certain  ones  are  much  more  often  involved  than  others;  the 

'Op.  cit,  p.  228. 


SYPHILIS    OF   THE   NERVOUS   SYSTEM.  217 

motors  of  the  eye,  the  seventh  pair,  the  fifth  pair,  and  the  spinal  nerves 
take  the  lead.  Among  the  nerves  of  special  sense,  the  optic  suffers  most 
often,  optic  neuritis  being  very  common  in  connection  with  syphilis  of  the 
brain,  the  portio  mollis  of  the  seventh  pair  coming  next  in  frequency, 
the  olfactory  third.  The  sense  of  smell  is  not  often  injured  except  in 
connection  with  ulcerative  or  necrotic  changes  within  the  nose,  and  the 
sense  of  taste  very  rarely  forsakes  a  patient  except  in  connection  with 
destructive  changes  in  the  mucous  membrane  of  the  pharynx  and  nose, 
or  extensive  gumma  of  the  tongue. 

The  nerves  running  to  the  muscles  of  the  eye  lose  their  power  very 
often  through  syphilis,  the  third  most  commonly  of  all.  When  the  func- 
tion of  the  third  nerve  is  interrupted,  or  of  portions  of  it,  the  result  is  ptosis 
(quite  common),  mydriasis  (very  common),  divergent  squint  (least  com- 
mon). Mydriasis  is  so  common  as  to  be  almost  constant  in  brain  syphilis. 
It  may  be  due  to  optic  neuritis  in  an  advanced  state;  anything  which 
blunts  the  sensitiveness  of  the  retina  to  light  will  make  the  pupil  dilate. 
When  mydriasis  occurs  alone,  as  it  often  does,  without  any  evidence  of 
retinal  cause  or  loss  of  function  of  the  third  nerve,  the  short  ciliary 
branches  coming  from  the  lenticular  ganglion  are  the  only  ones  which  func- 
tionate imperfectly.  The  lenticular  ganglion  presides  over  the  dilatation 
and  contraction  of  the  pupil  as  well  as  over  accommodation,  and,  as  Hutch- 
inson  '  has  pointed  out,  when  there  is  cycloplegia  (paralysis  of  the  cil- 
iary muscle)  and  a  motionless  pupil,  the  orbital  muscles  acting  well,  there 
must  be  disease  of  the  lenticular  ganglion,  and  this  condition  of  things 
does  sometimes  occur  in  connection  with  syphilis.  It  is  far  more  common, 
however,  to  find  mydriasis  occurring  alone,  all  the  other  muscular  condi- 
tions in  and  about  the  eye  being  normal.  Tait  and  Tuke  have  reported 
cases  of  long-persistent  myosis  due  to  syphilis. 

About  the  ptosis  and  the  squint  there  is  nothing  special  to  record. 
These  symptoms,  as  well  as  the  mydriasis  and  the  myosis,  yield  to  treat- 
ment of  the  stage  of  syphilis  in  which  they  occur.  The  mydriasis  is  per- 
haps, of  all,  the  most  persistent. 

The  patheticus  nerve  (fourth  pair)  has  been  reported  paralyzed  by 
syphilis  (Graefe),  and  the  sixth  pair  also  occasionally  suffers. 

Facial  neuralgia,  or,  more  rarely,  anaesthesia  due  to  syphilis  of  the  fifth 
nerve,  is  sometimes  encountered,  yielding  to  mercury  early  in  syphilis,  and 
more  slowly  to  the  iodides  later. 

Facial  paralysis  is  quite  common  in  syphilis.  Early  in  the  disease 
this  symptom  has  been  noted.  It  is  mild  in  character,  and  yields  to  mer- 
cury. Late  in  syphilis  it  may  come  on  alone  or  in  connection  with  other 
symptoms,  and  not  infrequently  it  is  the  forerunner  of  some  serious  out- 
burst; it  may  precede  a  general  attack  of  hemiplegia  by  several  days. 
It  yields,  sometimes  slowly,  to  mixed  treatment,  and  especially  to  the 
iodides  in  large  doses. 

The  other  pairs  of  nerves  are  very  seldom  involved  by 'syphilis,  but  they 
are  not  exempt. 

The  spinal  nerves  rarely  suffer  in  a  neuralgic  way,  but  paralyses,  an- 
aesthetic and  neuralgic  troubles,  may  involve  any  of  them  occasionally. 
Pleurodynia  is  common  in  the  anaemia  of  early  syphilis  and  in  the  cachexia 
of  the  tertiary  stage.  Sciatica  of  syphilitic  origin  is  not  common  or 
well  known,  but  undoubtedly  occurs.  N.  B.  Emerson,'  of  New  York,  in 

1  Lancet,  Feb.  10,  1877,  p.  199  (London  Path.  Society). 
8  Trans.  Am.  Neurological  Association,  N.  Y. ,  1877. 


218  THE    VENEREAL   DISEASES. 

an  excellent  paper  on  the  subject,  has  given  cases  occurring  early  arid  late 
in  the  disease. 

SYPHILIS    OF   THE    SYMPATHETIC. 

The  sympathetic  ganglia  are  not  left  unmolested  by  syphilis.  Petrow, 
in  1873,  called  attention  to  changes  produced  in  the  sympathetic  ganglia 
by  syphilis,  pigmentation,  and  colloid  degeneration  of  nerve-cells;  inter- 
stitial connective-tissue  hyperplasia  causing  atrophy  of  nerve  cells  and 
fibres;  enlargement  and  proliferation  of  the  endothelium  surrounding  the 
nerve-cells,  followed  by  fatty  degeneration. 

Hutchinson  believes  that  the  dyspepsia  of  syphilis  is  due  to  some  ob- 
scure disease  of  the  sympathetic  ganglia.  Disease  of  the  lenticular  gan- 
glion has  already  been  referred  to. 

In  cases  of  repeated  cerebral  congestion  due  to  syphilis,  Althaus '  pre- 
mises that  the  superior  cervical  ganglion  of  the  sympathetic  is  the  seat  of 
organic  change. 

As  may  be  observed  from  what  is  written  above,  the  effect  of  syphilis 
upon  the  sympathetic  system  are  mainly  conjectural.  Very  little  is  known 
about  it,  much  is  left  to  discover. 

Since  attention  of  late  years  has  been  especially  directed  toward  the 
nervous  symptoms  of  syphilis,  many  discoveries  have  been  made.  Four- 
nier's  recent  book  (La  syphilis  du  cerveau.  Paris,  Masson,  1879),  gives 
perhaps  as  complete  a  showing  of  the  subject  as  any  that  has  been  written, 
and  will  repay  perusal. 

1  Med.  Times  and  Gaz.,  Nov.  10,  1877. 


CHAPTER  XIII. 

SYPHILIS  OF  THE  GENITOURINARY  SYSTEM  IN  BOTH 

SEXES. 

Syphilis  of  the  Kidney. — Syphilitic  Albuminuria. — Syphilis  of  the  Penis. — Syphilis  of 
the  Testicle  ;  Epididymitis,  Orchitis  (Diffuse,  Gummatous). — Diagnostic  Table  of 
Syphilitic,  Tubercular,  Cancerous,  and  Sarcomatous  Enlargement  of  the  Testicle. 
— Treatment  of  Syphilis  of  the  Testicle. — Impotence  due  to  Syphilis. — Syphilis 
of  the  Genital  System  in  the  Female. — Functional  Derangements  of  Menstruation 
due  to  Syphilis. — The  Effect  of  Syphilis  upon  Pregnancy. — Cause  of  Abortion  in 
Syphilis. — Syphilis  of  the  Mammary  Gland,  Diffuse,  Parenchymatous,  Gumma- 
tous. 

SYPHILIS    OF   THE   KIDNEY. 

SYPHILIS  affects  the  kidneys  in  three  forms:  as  interstitial,  diffuse,  con- 
nective-tissue cell  hyperplasia,  as  gummy  tumor,  and  as  amyloid  degener- 
ation. 

The  diffuse  chronic  syphilitic  nephritis  is  similar  to  other  parenchyma- 
tous  forms  of  interstitial  nephritis,  except  that  it  is  more  apt  to  occur  in 
patches,  and  that  upon  section  small  clusters  and  collections  of  cells  (gum- 
mata),  are  often  found  scattered  through  it.  The  patches  of  circum- 
scribed disease  become  contracted  and  condensed  with  the  progress  of  the 
affection,  and  the  capsule  adheres  to  them. 

Gummata  are  not  often  met  with  in  the  kidney.  They  rarely  get 
larger  than  peas.  In  structure  they  resemble  gummata  of  other  organs. 
They  are  always  associated  with  more  or  less  diffuse,  parenchymatous 
nephritis,  each  gumma  being  situated  in  a  condensed  band  of  connective 
tissue.  Gummata  of  the  kidney  do  not  seem  to  exist  alone.  If  they  are 
found,  the  same  lesions  may  be  looked  for  in  the  liver  and  spleen  with 
confidence  that  they  will  be  discovered  there. 

Amyloid  degeneration  of  the  kidney  has  in  it  nothing  which  is  speci- 
fic. It  may  be  associated  with  other  lesions  due  to  syphilis,  or  exist 
alone.  In  the  latter  case  it  is  the  rule  to  find  the  liver  also  and  the  spleen 
to  be  amyloid;  but  this  degeneration  may  exist  in  all  these  organs,  and 
yet  the  patient  have  no  syphilis.  Nevertheless,  amyloid  degeneration  of 
the  viscera  is  common  enough  in  connection  with  late  syphilitic  cachexia 
to  have  attracted  general  attention;  and  although  the  change  is  not  in  it- 
self specific,  it  is  undoubtedly  in  some  way  often  due  to  syphilis  as  a  cause. 


SYPHILITIC   ALBUMINURIA. 

The  only  way  in  which  the  existence  of  syphilitic  lesions  of  the  kid- 
neys can  be  even  surmised  during  life  is  by  the  presence  of  albumen  in 
the  urine,  with  or  without  casts,  for  the  ordinary  tissue-changes  in  the 


220  THE    VENEREAL   DISEASES. 

organ  are  not  attended  by  local  pain  or  general  fever.  There  may  be 
symptoms  of  uraemia  (but  very  seldom)  and  general  anasarca  (equally  rare), 
but  I  am  not  aware  that  albuminous  retinitis  occurs;  and  often  there  are 
no  symptoms  at  all,  excepting  the  presence  of  albumen  in  the  urine,  to 
declare  that  the  kidneys  are  not  sound. 

Such  a  case  was  observed  by  me,  in  connection  with  Dr.  Van  Buren, 
in  the  person  of  a  patient  seen  in  consultation  with  Dr.  Dubois.  The 
urine  was  loaded  with  albumen,  so  as  sometimes  to  boil  into  a  solid  white 
mass,  and  it  never  contained  any  blood  or  pus.  No  casts  were  found,  the 
specific  gravity  ranged  high,  the  general  health  remained  perfect  in  all 
respects  (except  that  the  patient  grew  thin),  there  was  not  the  least  urae- 
mia or  swelling  of  the  face  or  legs,  and  occasionally  the  quantity  of  the 
albumen  in  the  urine  would  change  materially  without  cause. 

This  patient  eventually  recovered  entirely,  every  trace  of  albumen  dis- 
appearing from  the  urine,  which  became  as  light,  clear,  and  bright  as 
sherry,  and  remained  so  after  boiling  and  adding  nitric  acid. 

I  have  seen  several  other  cases  of  albuminuria,  which  came  on  during 
the  course  of  syphilis.  They  are  generally  unimportant,  and  get  well 
under  treatment.  I  am  certain  that  in  some  cases  slight  transient  albu- 
minuria is  produced  by  the  prolonged  use  of  iodide  of  potassium  in  large 
doses.  This  ceases  on  leaving  off  the  drug. 

Hans  Hebra1  reports  a  case  of  syphilitic  paraplegia  cured  by  treat- 
ment. A  month  later  the  patient  came  back  with  swollen  legs  and  intense 
albuminnria,  which  got  quickly  well  under  large  doses  of  the  iodide  of 
potassium.  M.  Bradley"  has  reported  general  anasarca  in  a  child  with 
inherited  syphilis,  four  months  old,  who  had  a  papulo-squamous  eruption 
and  aibuminuria.  Mercury  with  chalk  cured  the  child  of  its  skin  disease 
and  its  albuminuria  in  a  few  weeks.  This  child,  says  Bradley,  had  not 
had  scarlatina.  Bradley  also  remarks  that  he  found  albumen  in  the  urine 
of  two  out  of  twenty  patients  with  inherited  syphilis  whom  he  had  exam- 
ined, and  it  is  well  known  by  autopsical  evidence,  that  syphilis  of  the  kid- 
ney is  much  more  common  in  inherited  than  in  acquired  syphilis.  The 
diffuse  parenchymatous  form  is  most  often  met  with  in  inherited  disease. 

Syphilis  of  the  ureter  does  not  seem  to  occur.  Syphilis  appears 
also  to  spare  the  bladder,  except  in  connection  with  disease  of  the  spinal 
cord. 

SYPHILIS    OF   THE    GEXITAL    SYSTEM   IX   THE    MALE. 

The  penis  most  often  bears  the  brunt  of  the  attack  in  primary  syphi- 
lis in  being  the  seat  of  chancre  and  lymphangitis.  Later  in  secondary 
disease,  cutaneous  eruptions  occur  upon  it,  and  mucous  patches  and  ulcers 
•within  the  cavity  of  the  prepuce  and  (very  rarely)  within  the  urethra.  In 
tertiary  disease,  ulcerated  subpreputial  gumma  is  by  no  means  rare;  a 
papular  eruption  may  occur  within  the  urethra,  giving  rise  to  a  gleet.  I 
have  observed  once  such  a  case.  The  lumpiness  in  the  urethra  could  be 
felt,  and  it,  with  the  gleet,  disappeared  promptly  under  antisyphilitic 
medication  by  the  mouth. 

Finally,  in  tertiary  disease,  gummata  occasionally  occur  in  the  corpora 
cavernosa,  usually  in  the  anterior  third  of  the  organ;  they  are  very  rare, 
and  must  be  distinguished  from  chronic  circumscribed  inflammation  of 

VVierteljahresschrift  f.  Derm.  u.  Syph.,  No.  II.,  p.  35. 
1  British  Medical  Journal.  1871,  Vol.  I.,  p.  117. 


SYPHILIS    OF   THE    GEXITO-URINAKY    SYSTEM.  221 

the  sheaths  of  the  corpora  cavernosa '  and  from  calcification  of  the 
penis. 

Gumma  of  the  corpus  cavernosum  is  a  hard,  painless,  semi-elastic 
swelling  at  first.  It  causes  deflection  of  the  penis  when  erect,  toward 
the  side  upon  which  it  is  situated,  and  to  an  extent  proportionate  to  the 
size  of  the  growth.  In  structure  it  is  like  other  gummata.  It  goes 
on  to  reach  a  certain  size,  and  then  may  soften  and  shrivel  away,  or  be- 
come fibrous,  or  possibly  calcify.  I  do  not  know  of  any  case  personally 
where  a  gumma  of  the  corpus  cavernosum  has  softened  and  discharged 
externally.  General  calcification  of  the  penis  occurs  in  plates  upon  the 
sheath  of  the  corpus  cavernosum.  It  is  apt  to  be  general,  and  is  not  of 
syphilitic  nature. 

Chronic  circumscribed  inflammation  of  the  corpora  cavernosa  is  also 
mainly  superficial,  confined  to  the  sheath  and  underlying  tissue,  painful 
(somewhat)  to  pressure,  often  advancing  in  one  direction  as  it  gets  well 
in  the  other,  never  by  any  chance  suppurating,  occurring  spontaneously 
or  as  a  result  of  injury,  never  due  to  syphilis. 

The  last  two  affections  are  not  in  the  least  degree  helped  by  anti- 
syphilitic  treatment,  either  mercurial  or  by  the  iodides ;  but  gummy 
tumor  promptly  disappears  when  the  latter  remedy  is  boldly  pushed  in 
large  doses. 

The  prostate  does  not  appear  to  suffer  directly  from  syphilis.  Gum- 
ma in  this  region  is  possible,  but  very  rare. 

The  spermatic  cord  is  sometimes  the  seat  of  gummy  tumor,  and 
the  scrotum  a  favorite  locality  for  condylomata  and  scaly  patches  of  the 
circinate  sort. 

SYPHILIS    OF   THE    TESTICLE. 

Four  different  affections  attest  the  action  of  syphilis  upon  the  testicle: 

1.  Epididymitis. 

2.  Diffuse  orchitis. 

3.  Gummy  tumor. 

4.  Functional  impotence. 

They  may  all  be  arrested  and  cured  by  appropriate  treatment. 


SYPHILITIC    EPIDIDYMITIS. 

During  secondary  syphilis,  in  the  earlier  months — three  or  four  after 
chancre  (Dron) — there  may  appear  in  the  epididymis,  usually  at  its  head, 
on  one  or  both  sides  of  the  body,  a  round,  hard  tumor,  standing  distinct 
from  the  testicle,  and  not  capped  over  it  as  in  ordinary  chronic  epididy- 
mitis.  The  lump  varies  in  size,  but  generally  gets  to  be  as  large  as  a 
good-sized  marble.  It  is  attended  by  a  slight  amount  of  spontaneous  pain, 
increased  by  manipulation;  occasionally  the  swelling  is  perfectly  indolent, 
and  the  pain  is  never  so  great  as  that  experienced  in  ordinary  epididymitis. 

Nothing  more  is  known  of  the  affection  than  this.  I  have  encountered 
it  only  two  or  three  times.  It  is  quite  rare.  It  always  gets  well,  never 
has  been  known  to  soften,  and  no  autopsy  has  been  reported.  It  is  quite 
constant  in  its  appearance  at  the  globus  major,  and  does  not  extend  to 

1  Van  Buren  and  Keyes :  Gen.  Urinary  Diseases  and  Syphilis.    N.  Y. ,  1874,  p.  24. 


222  THE   VENEREAL    DISEASES. 

the  body  of  the  epididymis,  or  to  the  globus  minor.  It  never  involves 
the  testicle.  Rollet  places  the  outside  limit  of  its  existence  at  two 
months  from  its  first  appearance. 

Treatment  is  mercurial.  No  variation  is  required  from  that  in  use 
for  the  stage  of  syphilis  in  which  the  affection  occurs.  Local  measures 
are  unnecessary.  The  patient  need  not  alarm  himself  about  the  lump. 
Unlike  the  chronic  thickenings  left  in  the  body  and  tail  of  the  epididymis 
after  gonorrhoeal  epididymitis,  the  syphilitic  form  does  not  occupy  the 
calibre  of  the  tubes,  or  occlude  them  by  pressure,  as  proved  by  Dron,  who 
found  spermatozoa  in  the  semen  of  a  patient,  both  of  whose  testicles 
were  the  seat  of  this  affection. 


SYPHILITIC   OKCHITIS. 

In  the  tunica  albuginea,  and  in  the  fibrous  septa  running  between  the 
clusters  of  seminal  tubules,  usually  commencing  at  the  circumference, 
perhaps  generalized  through  the  whole  parenchyma,  sometimes  confined 
to  a  limited  area,  a  cellular  overgrowth  of  the  connective-tissue  elements 
may  arise  due  to  syphilis,  constituting  diffuse  sj^philitic  orchids. 

This  new  tissue  develops  until  it  has  reached  a  certain  limit,  and  then 
contracts  upon  itself,  squeezing  the  secreting  elements  of  the  testicle,  and 
finally  reducing  the  whole  gland  to  a  fibrous  cicatricial  nodule  of  small 
size,  or  producing  depressions  and  seams  which  mark  the  limited  areas  of 
disease  and  distort  the  gland  more  or  less.  Along  with  the  other  changes 
in  the  organ  the  tunica  vaginalis  becomes  thickened,  and  its  cavitv  oblit- 
erated by  cohesion  of  its  two  surfaces,  or  cut  up  into  partitions  by  partial 
adhesions. 

The  result  of  the  anatomical  changes  is  a  gradual,  general  enlargement 
of  the  organ  or  a  localized  patch  of  induration,  usually  the  former.  After 
a  time  the  organ  atrophies,  with  or  without  treatment,  and  gets  to  be  a 
mere  fibrous  knot,  or,  in  any  case,  smaller  than  it  originally  was.  Suppu- 
ration never  occurs. 

Syphilitic  orchitis  is  a  late  symptom,  rarely  appearing  during  the  first 
year  of  the  disease,  and  sometimes  coming  on  long  after  all  symptoms 
have  ceased.  It  is  occasionally  found  in  inherited  syphilis. 

The  symptoms  are  an  insidious  swelling  of  one  or  both  testicles  with- 
out pain.  Generally  the  patient  finds  out  by  accident  that  one  of  his  tes- 
ticles is  unnaturally  large  and  hard.  Squeezing  such  a  testicle  in  the  hand 
causes  the  patient  little  or  no  pain,  and  the  organ  feels  to  the  hand  as  hard 
as  wood.  It  preserves  its  oval  shape — the  epididymis  is  indistinguishable 
from  the  body  of  the  testicle — the  cord  is  not  involved,  the  tunica  vaginalis, 
instead  of  being  obliterated,  may  be  full  of  fluid. 


GUMMY  TUMOR   OF  THE   TESTICLE. 

Gumma  of  the  testis  is  less  common  than  diffuse  orchitis.  With  gumma 
there  is  generally,  also,  more  or  less  fibrous  thickening.  Small  gummata 
are  generally  scattered  through  the  morbid  fibrous  tissues  of  the  organ — 
large  ones  surrounded  by  condensed  fibrous  tissue,  like  a  capsule.  The 
gumma  is  at  first  purely  cellular;  finally  it  is  found  as  a  fine,  fibrous  felt- 
ing, the  seat  of  amorphous  granulo-fatty  degeneration.  In  the  cheesy 
centre,  plates  of  cholesterine  are  sometimes  found  (Virchow). 


SYPHILIS    OF   THE    GENITO-URINAKY   SYSTEM.  223 

The  gumma  is  recognized  as  a  distinct  tumor  perhaps  accompanying 
the  physical  changes  indicative  of  diffuse  orchitis.  It  is  painless.  The 
nodule  grows  to  a  certain  size,  then  softens  centrally  and  undergoes  cheesy 
degeneration,  or,  infiltrating  the  tunica  albuginea,  the  two  surfaces  of  the 
tunica  vaginalis  adhere,  and  the  skin  becomes  attached  over  the  swelling 
mass.  Finally  the  skin  softens,  ulcerates,  and  lets  out  the  gumma,  which 
bears  with  it  the  contents  of  the  testicle,  the  whole  mass  protruding  out- 
side and  constituting  one  form  of  benign  fungus  of  the  testicle.  This  fun- 
gus grows  larger  on  account  of  an  increased  formation  of  gummy  material 
•within  the  tunica  albuginea,  the  surface  of  the  protruded  portion  becomes 
covered  with  granulations  and  bathed  in  a  scanty  pus.  The  yellow,  de- 
generated, gummatous  matter  is  found  lying  between  clusters  and  coils 
of  seminal  tubules,  which  may  be  carelessly  pulled  out  by  the  unwary 
practitioner  under  the  idea  that  they  are  dead,  sloughy,  and  of  no  service. 
The  tissues  of  the  scrotum  contract  around  the  base  of  the  fungus,  mak- 
ing it  pedunculated.  The  whole  mass  is  hard,  insensitive,  not  bleeding 
easily. 

If  the  affection  be  not  arrested  by  treatment,  its  natural  termination 
is  to  go  on  until  the  whole  of  the  contents  of  the  tunica  albuginea  have 
been  extruded,  after  which  the  mass  dries  down  and  puckers,  leaving  the 
wasted  stump  of  the  testicle  attached  to  the  cicatrix  in  the  scrotum. 

The  epididymis  is  sometimes  the  seat  of  gummy  tumor,  but  rarely;  and 
the  cord  (Verneuil)  also  occasionally. 

The  symptoms  of  syphilitic  testicle,  besides  the  changes  of  form 
already  described  for  the  diffuse  and  gummatous  form,  are:  diminution 
or  absence  of  sexual  desire,  and  often  entire  absence  of  erections. 

The  diagnosis  of  syphilitic  testicle  is  often  difficult.  There  is  no  possi- 
ble danger  of  mistaking  it  for  gonorrhoaal  epididymitis,  or  any  other  acute 
inflammatory  affection  of  the  epididymis  or  testicle;  the  intense  pain  in 
these  maladies,  both  spontaneously  and  upon  handling  the  organ,  excludes 
syphilitic  testis  from  diagnostic  consideration  when  it  is  in  question. 
Nor  is  there  any  considerable  chance  of  the  error  of  mistaking  chronic  epi- 
didymitis, the  pseudo-tubercular  testis,  for  syphilitic  disease  of  the  organ. 
The  lumpy  condition  of  the  epididymis  capping  the  soft  testicle  above,  or 
hanging  down  as  a  cheesy  nodule  below  the  tail  of  the  epididymis,  perhaps 
softening  into  abscess  and  becoming  fistulous,  but  leaving  the  soft,  elastic 
testicle  intact  in  its  peculiar  natural  sensibility;  this  chronic  malady  has 
nothing  in  common  with  syphilitic  testicle,  and,  although  it  may  occasion- 
ally suggest  the  syphilitic  epididymitis  of  Dron,  yet  its  chronic  course  and 
peculiar  pathological  physiognomy  will  readily  distinguish  it  from  the 
more  innocent  syphilitic  affection. 

It  is  still  insisted  upon  by  Curling  and  others  that  there  is  a  simple 
inflammatory  orchitis,  a  sarcocele,  which  is  neither  tubercular  nor  syphi- 
litic. This  is  possible,  but  exceptionally  rare.  I  have  occasionally  en- 
countered a  case  clinically  where  no  other  diagnosis  but  this  seemed  pos- 
sible, yet  it  is  a  good  rule  to  adopt  Sir  Astley  Cooper's  method  and  never 
to  cut  out  an  inflamed  testicle  until  mercury  has  had  a  full  chance;  and, 
it  may  be  added,  the  iodide  of  potassium  as  well.  A  benign  fungus  has 
also  been  described,  but  it  is  much  more  uncommon  than  syphilitic  fungus. 

The  main  difficulties  in  diagnosis  of  syphilitic  testicle,  however,  are 
hydrocele,  tubercle,  cancer,  and  sarcoma  of  the  testicle.  Hydrocele  is  not 
important.  Many  syphilitic  testicles  are  so  surrounded  by  the  fluid  of  a 
hydrocele  that  their  physical  characters  are  entirely  obscured.  In  no  case 
is  it  safe  to  decide  that  a  hydrocele  is  a  simple  matter  until  it  has  been 


224 


THE    VENEREAL    DISEASES. 


tapped  and  the  testicle  examined.  If,  after  tapping,  the  physical  signs 
are  those  of  syphilis  of  the  testicle,  no  radical  treatment  of  the  effusion  in 
the  tunica  vaginalis  should  be  undertaken;  both  because  it  is  likely  to 
fail,  and  because  it  is  unnecessary,  since  antisyphilitic  treatment  will  re- 
move the  effusion  together  with  the  lesion  of  the  testicle. 

Tubercular  testis,  however,  is  often  painless;  and  certain  stages  of 
cancer  of  the  testicle  and  of  sarcoma  are  suggestive  of  syphilis.  The 
salient  points  of  clinical  difference  between  these  affections  can  be  best 
presented  in  the  form  of  a  short  diagnostic  table. 

Diagnostic  Table. 


•YPHILITIO  TESTICLE. 

TUBERCULAR  TESTICLE. 

CANCEROUS   TESTICLE. 

SABCOMATOUS  TESTICLE. 

1.  Date  of  appearance 

Adolescence. 

Youth. 

Youth. 

generally.  —  Middle  age. 

2.  Size.—  Karely  larger 

Often    larger    than    a 

Sometimes    enormous, 

Often   very  large,  but 

than  a  goose-egg. 

goo&e-egg. 

weighing  several  pounds. 

generally  becoming  can- 

cerous   when    it    attains 

great  size. 

3.    Commencement.  — 

Generally  in  the  testi- 

Always in  the  testicle. 

Always  in  the  testicle. 

Generally  in  the  epididy- 

cle. 

mis. 

4.  Growth.  —  Insidious, 

Slow;  of  ten  lasts  many 

Rapid;  average   about 

Slow  at  first,  often  rapid 

often  unnoticed,  may  last 

years. 

two  years. 

later  on  ;  total  duration 

several  years. 

many  years. 

•6.  Physiognomy.  — 

Nodular,  occupying  the 

Unevenly  lobulated  in 

Generally    even,     or 

Smooth  andeven  through- 

epididymis ;  scrotum  of- 

various directions  ;   veins 

slightly   lobulated  ;  scro- 

out, or  containing  one  or 

ten  reddened  and  hot. 

of  scrotum  often  enlarged, 

tum  unchanged. 

more  nodules  in  the  tes- 

integument unchanged. 

ticle;  scrotum  unchanged. 

6.  Induration.  —  Very 

Not  marked,  the  feel  is 

The  lobules  present  dif- 

Solid, meaty  feel,  not 

strongly  marked,  woody. 

elastic. 

ferent    degrees  of    hard- 

very   hard  ;    thi  re    may 

ness  ;  some  of  them  seem 

be   a  cyst  which  fluctu- 

to fluctuate. 

ates. 

7.  Spontaneous  pain.  — 

Insignificant,  as  a  rule. 

Present  in  paroxysms, 

Absent. 

Absent. 

often  very  sharp. 

8.  Pain  on  handling.  — 

Generally  absent  ;  nor- 

Pain increased  by  hand- 

Absent ;  normal  sensi- 

Generally absent;  normal 

mal  sensibility  gone. 

ling  ;  no  natural  testicular 

bility  gone. 

sensibility  gone. 

sensation. 

9.  Fluid  in  tunica  va- 

Not unusual. 

In  small  amount. 

Usually  absent. 

ginalis.  —  Common. 

10.  Softening  and  dis- 

Softening and  abscess 

Rather  common,  leav- 

Does not  occur. 

charge.  —  Rather   excep- 

the rule,  leaving  fistula. 

ing  malignant  fungus. 

tional  :  sometimes  occurs, 

leaving  fungus. 

11.  Often     bilateral, 

Often  bilateral  consecu- 

Very rarely  bilateral. 

Hardly  ever  bilateral. 

simultaneously    or     con- 

tively. 

secutively. 

12.    Sexual   power.  — 

Sometimes  diminished, 

Not    impaired,    except 

Not  impaired. 

Diminished  or  absent. 

often  not  impaired. 

by  size  and  i>ain. 

18.  Fungus      found 

Abscess     and      fistula 

Fungus    found    some- 

No fungus. 

sometimes,     of     small 

found,   but    not  fungus. 

times    growing    rapidly. 

growth,  pale,  not  bleeding 

except  in   the  shape    of 

livid    in    color,    bleeding 

easily. 

simple  granulations. 

very  easily. 

13.  Inguina  andpelvic 

Normal  or  tender  from 

Enlarged  cancerous. 

Not  involved  while  the 

glands.  —  Normal. 

simple  inflammation. 

tumor  remains  benign. 

14.   Spermatic  cord.  — 

Generally  involved 

Often     implicated    to- 

Always normal. 

Rarely  implicated. 

after  a  time. 

ward  the  end. 

15.  Seminal  vesicles.  — 

Frequently  diseased. 

Normal. 

Normal. 

Normal. 

16.    Treatment.  — 

Quite    unsatisfactory  ; 

Prompt    castration    is  •      Prompt  castration  de- 

Promptly  satisfactory  in  !  cure  possible,   but    very 

necessary,  and  affords  the    sirable  to  prevent  the  tes- 

case  of   gummy  tumor  ;  \  slow,  if  accomplished  at 

only  hope  of  saving  the    tide  from  becoming  can- 

often  very  slow  in  its  ef-  '  all  ;  general  tubercnliza- 

patient's  life. 

cerous,  since  sarcoma  m 

fects,  if  the  malady  has  ,  tion  quite  apt  to  come  on 

this    region    often    runi 

already  existed  for  some  !  and  terminate  the  case  ; 

into  cancer. 

time  in  the  diffuse  form  ;  1  castration  is  often  justi- 

treatment    necessary    to  i  liable. 

save  testicle  from  atrophy, 

which  can  always  be  ac- 

complished   when    treat- 

ment  is    commenced    in 

time. 

\ 

SYPHILIS    OP    THE    GENTTO-UKINAKY    SYSTEM.  225 

Treatment. — Syphilitic  testicle  in  the  diffuse  form  calls  for  mercury 
as  well  as  the  iodide  of  potassium.  Local  treatment  is  of  little  or  no 
value,  but  a  suspensory  bandage  should  be  used  to  protect  the  enlarged 
organs  from  injury.  Mercury  may  be  employed  by  general  inunction. 
Local  inunction  of  the  scrotum,  or  the  wearing  of  plasters  upon  it,  is 
dirty,  and  possesses  no  superior  merit.  The  effect  of  treatment  is  slow, 
but  it  should  be  persisted  in  to  save  whatever  of  the  glandular  structure 
is  possible  from  atrophy.  The  iodide  should  be  pushed  up  to  large 
doses  (twenty  grains  or  thereabouts),  and  the  effect  watched.  If  a  re- 
turn of  sexual  appetite  and  a  reduction  in  the  size  of  the  gland  are  not 
quite  noticeable  within  a  month,  it  is  better,  for  the  stomach's  sake,  to 
reduce  the  dose  of  the  iodide  to  five,  or,  at  most,  ten  grains,  and  push 
the  mercurial  by  inunction  until  the  mouth  is  mildly  touched.  After 
this  the  dose  of  the  mercurial  may  be  also  diminished,  and  pressure  of 
the  testicle  (by  strapping)  combined  with  a  moderate  internal  mixed 
treatment. 

For  gummy  tumor,  the  iodides  alone  are  needed,  in  doses  as  large  as 
the  stomach  can  conveniently  manage.  A  prompt  effect  is  to  be  ex- 
pected. 

Fungus  of  the  testicle  should  on  no  account  be  molested  by  local 
treatment.  If  it  becomes  strangulated  and  threatened  with  gangrene, 
it  is  proper  to  liberate  the  neck  of  the  fungus  from  its  pressure  by  suit- 
able incisions  through  the  skin,  dartos,  and  albuginea.  Otherwise  the 
fungus  must  be  left  alone,  covered  by  a  piece  of  lint  smeared  with  vase- 
line, to  protect  it  from  friction  and  injury.  The  iodide  of  potassium, 
given  in  sufficient  doses,  will  soon  cause  the  gummatous  deposit  within 
the  tunica  albuginea  to  be  absorbed,  and  all  the  seminal  tubules  within 
the  fungus,  which  have  escaped  destruction  by  pressure,  will  be  naturally 
drawn  back  within  the  cavity  of  the  testicle.  Toward  the  end,  a  little 
pressure  may  hasten  the  disappearance  of  the  fungus  and  the  cicatriza- 
tion of  the  wound. 

FUNCTIONAL,   IMPOTENCE. 

Syphilis  may  cause  functional  impotence,  not  due  to  any  physical 
lesion  of  the  testicles.  In  the  tertiary  stage,  impotence  may  come  on 
independently  of  any  cachexia,  the  testicles  appearing  normal  in  size,  and 
possessed  of  their  peculiar  sensibility,  but  perhaps  feeling  a  little  flabby, 
as  if  less  full  of  blood  than  usual;  under  these  circumstances,  the  patient 
may  lose  all  sexual  desire,  and  absolutely  all  power  of  erection. 

This  condition  is  certainly  due  to  some  impression  upon  the  nervous 
system.  There  is  a  very  positive  bloodlessness  of  the  penis,  and  testicles. 
Treatment  often  restores  power,  and  then  the  organs  regain  their  plump- 
ness. The  affection  is  not  due,  as  has  been  claimed,  to  the  use  of  the 
iodides,  or  to  any  wasting  influence  their  prolonged  use  exercises  upon 
glandular  structure.  Patients  have  this  form  of  impotence,  who  have 
never  taken  the  iodides — patients  whose  symptoms  have  all  been  con- 
trolled by  mercurials.  Moreover,  the  iodides,  internally,  constitute  the 
best  treatment  for  the  malady. 

One  reason  why  the  iodides  have  been  accused  of  causing  atrophy  of 
the  testicles  is,  doubtless,  because,  in  many  cases  of  advanced  gummatous 
orchitis,  the  iodides  produce  at  first  a  diminution  of  the  enlarged  testicle, 
and,  during  the  continuance  of  the  medicine,  the  gland  atrophies  away 
to  a  stump.  The  iodides  are  now  accused  of  this  catastrophe,  whereas  the 
15 


226  THE    VENEREAL  DISEASES. 

truth  is  that  all  the  secreting  structure  of  the  testis  was  already  de- 
stroyed, and  replaced  by  newly  formed  tissue  before  treatment  was  com- 
menced. The  atrophy  was  inevitable.  Truly,  its  appearance  was  has- 
tened by  the  iodides,  but  not  caused  by  them;  and  the  trouble  was  that 
treatment  was  commenced  too  late  to  save  an  organ  already  pathologi- 
cally doomed  to  destruction. 

There  is  no  special  diagnostic  feature  which  distinguishes  functional 
impotence,  due  to  syphilis,  from  the  same  affection  dependent  upon  other 
causes  (generally,  moral;  sometimes,  gouty);  but,  when  a  patient,  having 
formerly  had  syphilis,  complains  of  failing  sexual  appetite  and  power,  it 
is  always  allowable  to  suspect  that  the  influence  of  the  old  disease  upon 
the  nerves  regulating  the  sexual  sense  is  the  cause  of  the  trouble,  and 
the  prognosis  at  once  becomes  proportionately  less  severe  than  it  would 
have  been  had  no  former  syphilis  existed. 

Treatment. — The  best  treatment  for  functional  syphilitic  impotence 
is  mixed  internal  medication  in  reasonably  mild  form,  persistently  pushed. 
The  effect  of  treatment  is  slow,  but  often  very  manifest.  A  perfect  cure 
is  possible.  Other  measures,  such  as  tonics,  change  of  air,  general  fric- 
tions to  the  whole  surface  of  the  body,  shower-baths,  etc.,  may  be  used, 
but  they  hold  a  place  second  to  that  occupied  by  antisyphilitic  treatment. 

I  have  encountered  a  number  of  these  cases,  totally  disconnected  with 
pathological  tissue-changes  in  the  testicles,  and  am  confident  that  the  af- 
fection exists  as  a  special  malady,  and  that  it  is  curable  by  antisyphilitic 
treatment. 


SYPHILIS    OF   THE    GENITAL   SYSTEM   IT*   THE   FEMALE. 

The  female  genitals  are  the  common  seat  of  chancre,  erosions,  and 
mucous  patches.  Tertiary  tubercular  patches  are  found  within  the  vagina, 
and  tertiary  brawny  infiltrations,  leading  to  ulcers  which  are  very  chronic 
in  their  course.  Gummata  in  this  region  may  perforate  one  or  the  other 
of  the  vaginal  septa.  Excepting  from  possible  mucous  patches  in  its 
cavity,  the  unimpregnated  uterus  does  not  appear  to  suffer  from  syphilis. 
Lancereaux  describes  a  case  of  gummy  tumor  of  the  ovary  similar  to  the 
same  lesion  in  the  testicle,  and  both  he  and  Hutchinson  have  encountered 
some  cases  of  imperfect  sexual  development  in  the  female,  in  connection 
with  congenital  syphilis,  making  it  seem  probable  that  parenchymatous 
ovaritis  is  possible  in  hereditary  syphilis,  as  parenchymatous  orchitis  and 
gumma  of  the  testicle  in  the  male  are  known  to  be. 

Gummata  have  been  found  in  the  Fallopian  tubes. 

Functional  derangements  of  menstruation  are  very  common  in 
women  with  syphilis.  In  the  secondary  stage,  anaemia  leads  to  scanty 
menstruation,  the  relaxed  ligaments  allow  the  organ  to  become  easily  dis- 
placed. Hence  arise  all  sorts  of  malpositions  with  catarrhal  states  of  the 
uterine  cavity,  painful  menstruation,  sterility,  hysteria,  etc.,  due  to  gen- 
eral causes  rather  than  the  specific  action  of  syphilis.  Metrorrhagia  may 
also  come  on — by  what  mechanism  does  not  seem  evident. 

The  cachectic  stage  of  tertiary  syphilis  also  leads  to  uterine  derange- 
ments and  induces  a  premature  change  of  life. 

Treatment  of  these  uterine  derangements  is  that  of  the  stage  of  syph- 
ilis in  which  they  occur,  together  with  such  local  measures  as  each  indi- 
vidual case  may  call  for. 


SYPHILIS    OF   THE   GENITO-UKINAEY   SYSTEM.  227 


THE   EFFECT   OF   SYPHILIS   UPON   PBEGNANCY. 

When  a  woman  is  in  active  syphilis,  she  rarely  carries  a  child  to  term. 
At  first  it  is  customary  for  such  a  woman  to  abort  at  or  about  the  third 
month  of  utero-gestation.  Such  a  woman  may  have  been  poisoned  by 
her  husband,  and  had  a  chancre  without  knowing  it.  Her  sore  throat 
may  have  been  transient,  her  first  eruption  so  light  as  not  to  have  at- 
tracted attention;  but  she  finds  her  color  fading,  her  hair  growing  dry 
and  falling  out,  her  scalp  getting  scurfy,  her  face  wearing  a  pinched  and 
wearied  expression.  She  is  evidently  anaemic;  she  feels  languid,  listless, 
incapable  of  undertaking  anything,  and  at  the  present  day,  since  the 
fashion  so  goes,  she  generally  passes  for  being  malarial. 

Such  a  woman,  without  any  obvious  ;signs  of  syphilis  about  her,  does 
not  thrive  upon  any  regimen,  or  tonic  course,  or  quinine,  or  change  of  air, 
so  well  as  she  does  upon  a  combination  of  blue  mass  and  dried  sulphate  of 
iron,  or  a  mild  dose  of  corrosive  chloride  of  mercury  in  compound  tinc- 
ture of  bark.  Such  a  tonic  suits  her.  The  mercurial  element  always 
brightens  her  up,  and  sends  the  blood  again  to  her  faded  cheeks. 

A  woman  under  these  circumstances  will  usually  abort.  Should  she 
become  pregnant  again,  she  will  again  abort,  but  probably  at  a  later 
month  of  utero-gestation.  Again  pregnant,  she  again  aborts;  on  this 
occasion,  perhaps,  miscarrying  at  the  seventh  month.  The  next  attempt 
may  produce  a  dead-born  child,  with  its  skin  commencing  to  come  off. 
Finally  a  child  will  be  born  at  term  alive,  perhaps  plump  and  clean-skinned, 
but  in  from  two  to  four  weeks  it  begins  to  fall  away  in  flesh,  gets  snuffles, 
sore  mouth,  eruptions,  jaundice,  and  dies;  another  child  appears  and  dies 
in  a  convulsion  after  a  few  months  of  life,  or  perishes  by  marasmus  in  its 
second  summer.  At  last  a  fat  child  is  born  seemingly  healthy,  but,  as  it 
grows,  its  fontanelles  close  too  rapidly,  it  is  microcephalic,  looks  like  an 
old  man,  is  perhaps  very  precocious,  but  it  has  a  harsh  cry,  contracted 
jaws,  bad  teeth;  the  second  set  are  syphilitic  teeth.  It  has  a  syphilitic 
countenance,  and  grows  up,  perhaps,  dwarfed  or  deformed  in  its  bones,  to 
fall  a  victim,  possibly,  to  gummatous  lesions  of  the  bones,  the  brain,  the 
eye,  or  the  viscera  during  development  into  manhood. 

After  this  the  mother  will  produce  a  perfectly  healthy  child,  if  her 
own  health  be  good.  Her  subsequent  offspring  will  not  probably  be  de- 
formed. They  will  not  be  strumous.  There  is  no  change  of  type  by 
transmitted  inheritance.  A  child  may  be  weakly,  if  the  mother  or  father, 
or  both,  be  in  poor  health,  or  from -a  variety -of  causes  ;  but  if  the  parent 
is  syphilitic,  the  child  is  either  syphilitic  or  healthy,  so  far  as  the  syphilis 
essentially  has  anything  to  do  with  the  matter. 

Now,  during  all  this  time  above  detailed,  a  mercurial  treatment  given 
to  the  mother,  by  inunction,  or  internally,  during  the  whole  course,  or  the 
greater  part  of  her  pregnancy,  will  generally  cause  her  to  produce  a 
healthy  child — a  child  who  not  only  is  healthy  at  birth,  but  remains 
healthy,  and  does  not  require  treatment.  Treatment  rarely  has  so  good 
an  effect  if  used  in  the  first  pregnancy.  Then  the  syphilitic  poison  is  too 
strong.  A  live  child  may  be  born  reasonably  healthy,  but  its  health  is 
not  assured,  and  it  may  demand  treatment  to  preserve  it  from  injury  by 
the  development  of  hereditary  syphilis. 

Again,  if  a  mother  has  produced  a  healthy  child  under  treatment,  she 
must  go  on,  and  at  her  next  pregnancy  again  take  a  full  mercurial  course, 
although  she  may  have  had  no  symptoms  of  syphilis  during  a  number  of 


228  THE    VENEREAL    DISEASES. 

years,  or  she  will  run  the  risk  of  again  producing  a  diseased  child. 
During  how  many  pregnancies  this  must  be  kept  up  is  not  known,  but 
cases  are  on  record  where  the  successful  production,  under  mercury,  of  two 
healthy  children  successively  (the  eighth  and  ninth,  all  the  previous  chil- 
dren having  died  syphilitic),  did  not  succeed  in  rendering  the  mother  ca- 
pable of  bringing  a  non-syphilitic  child  into  the  world.1  In  cases  of  this 
sort,  therefore,  it  will  be  wiser  to  medicate  the  mother  at  least  through 
three  successive  pregnancies  before  allowing  her  to  try  the  experiment  of 
passing  through  a  term  of  utero-gestation  unaided  by  drugs. 


CAUSE    OF   ABORTION    IN    SYPHILIS. 

Exactly  what  it  is  that  causes  abortion  and  premature  delivery  so 
often  when  the  parents  are  syphilitic,  is  not  certainly  known.  Disease 
and  death  of  the  foetus  does  not  necessarily  bring  on  premature  delivery, 
for  a  dead  child  is  often  carried  to  term.  If  the  germ  is  so  blighted  that 
its  development  into  a  foetus  is  impossible,  abortion,  perhaps,  is  natural  ; 
but  the  main  trouble  seems  often  to  lie  in  the  placenta.  The  question 
whether  syphilitic  uterine  disease  is  a  prime  factor  in  causing  the  placen- 
tal  changes,  or  whether  the  latter  owe  their  origin  to  a  blighted  ovum, 
does  not  appear  to  have  been  clearly  decided.  Finally,  whether  the  pla- 
cental  changes  have  in  them  anything  which  can  be  called  specific,  or  whe- 
ther they  are  such  as  may  occur  in  other  morbid  states,  not  syphilitic,  is 
also  undecided. 

The  syphilitic  placenta,  as  described  by  Fraenkel,  of  Breslau,"  under 
the  name  of  disfiguring  granulation-cell  disease,  consists  in  a  multiplica- 
tion of  the  cellular  elements  of  the  villi  and  of  their  epithelial  coating, 
together  with  an  increase  of  thickness  in  the  vessel-walls.  By  this  pro- 
cess, which  Fraenkel  thinks  goes  on  centrifugally  from  the  vessel,  the 
villi  increase  in  size,  then  the  vessels  become  occluded,  and,  finally,  the  villi 
atrophy.  The  unaffected  villi  become  congested,  extravasations  of  blood 
take  place,  and  the  foetus  suffocates,  because  its  blood  cannot  be  aerated 
in  the  diseased  placenta. 

This  occurs,  Fraenkel  thinks,  when  the  origin  of  the  disease  in  the 
foetus  is  syphilis  of  the  father.  When  the  mother  is  the  source  of  the 
transmitted  syphilis,  the  maternal  placenta  is  diseased,  there  is  an  in- 
creased growth  of  connective  tissue  in  the  framework  of  the  placental  de- 
cidua,  hypertrophy  of  the  cells  of  the  decidua,  and  atrophy  of  the  villi  by 
compression. 

The  syphilitic  nature  of  the  foregoing  changes  is  denied  by  Lawson 
Tait,'  who  believes  that  the  same  lesions  may  be  due  to  causes  other  than 
syphilis. 

Fatty  and  amyloid  degeneration  of  the  placenta  has  been  considered 
to  be  dependent  upon  syphilis,  and  a  cause  of  miscarriage,  and  tumors  re- 
sembling gummata  have  been  observed  in  the  placenta;  but  the  truth  is, 
that  this  field  is  not  yet  thoroughly  worked  out,  and  we  simply  know, 
clinically,  that  the  placenta  is  often  abnormal  histologically,  and  that  the 

1  Thurman's  case  :  Journ.  de  med.  et  de  chir.     Toulouse.  Oct.,  1851. 

*  Ueber  Placentarsyphilis :  Archiv  f.  Gynaekologie,  Vol.  V.,  1873,  p.  45.  These 
riews,  given  by  Angus  Macdonald.  may  be  found  in  the  American  reprinb  of  Obstetrical 
Journal  of  Great  Britain  and  Ireland/October,  1875,  p.  472. 

1  Transactions  London  Obstetrical  Society.     London,  1876,  p.  326. 


SYPHILIS    OF   THE    GENITOURINARY   SYSTEM.  229 

product  of  conception,  itself  more  or  less  diseased,  is  often  thrown  off  be- 
fore term. 

Treatment. — The  condition  of  affairs  described  above  may  certainly 
be  averted  by  treatment.  Mercurial  treatment  is  of  the  most  value.  The 
iodides  have  little  or  no  power  in  averting  the  tendency  of  syphilitic 
women  to  miscarry.  Mercury  will  generally  do  this,  and  when  it  accom- 
plishes the  result,  it  does  so  without  injury  to  either  the  child  or  to  the 
mother. 

The  manner  of  giving  mercury,  under  these  circumstance,  is  unimpor- 
tant, provided  enough  is  given.  Inunction  is  highly  praised  by  some  au- 
thorities. The  objection  to  inunction  is,  that  it  is  dirty,  not  suitable  to 
the  sex,  and  that  it  is  difficult  to  grade  the  dose  accurately,  according  to 
the  necessities  of  the  patient.  A  given  amount  of  mercury  does  not  af- 
fect all  people  in  a  similar  way.  Some  patients  have  a  boundless  toler- 
ance of  it,  while  others  become  salivated  with  great  facility.  In  the  preg- 
nant state  there  are  no  symptoms  to  be  guided  by,  and  the  value  of  the 
mercurial  course  can  only  be  decided  at  the  end  of  pregnancy,  when  it  is 
too  late  to  increase  the  do'se  if  it  has  not  proved  efficient. 

Consequently  it  is  best  to  have  some  rule  for  guidance.  The  method 
I  have  adopted  is  the  following:  I  use  an  unirritating  form  of  mercury 
combined  with  a  tonic — such  as 

3  •     Pil-  hydrargy  ri gr.  c. 

Ferri  sulph.  exsiccat gr.  1. 

M.     Ft.  pil.  L 
Or— 

$ .     Pil.  hydrarg gr.  c. 

Quinine  bisulph gr.  1. 

M.     Ft.  pil.  1. 

Commencing  at  the  beginning  of  pregnancy,  one  of  these  pills  is  to  be 
used  after  each  meal  (three  a  day)  for  a  week.  Then  four  pills  a  day  afre 
used  for  a  week,  then  five  pills  a  day  for  a  week,  and  so  on  until  the  med- 
icine begins  to  disagree.  When  the  mouth  becomes  a  little  touched,  all 
medication  is  suspended  for  a  week,  and  then  a  dose,  two-thirds  of  what 
was  found  necessary  to  touch  the  mouth,  is  commenced  with  and  given 
regularly.  It  may  be  alternated,  from  time  to  time,  with  a  mild  dose  of 
corrosive  sublimate  in  compound  tincture  of  bark.  It  may  be  intermitted 
entirely  for  a  time,  and  replaced  by  inunctions  of  the  oleate  of  mercury 
or  of  mercurial  ointment,  to  let  the  stomach  rest — a  drachm  being  used 
of  the  oleate  (ten  per  cent,  squibb)  daily,  or  less,  and  after  a  short  time 
the  internal  medication  being  resumed. 

If  the  stomach  becomes  irritated  by  the  prolonged  use  of  mercury,  in- 
unctions must  be  relied  upon  in  quantity  regulated  by  the  tolerance  of 
the  patient.  If  the  prolonged  use  of  a  mild  dose  internally  keeps  the 
mouth  tender,  the  hygiene  of  the  mouth  must  be  attended  to,  alkaline 
mouth  washes  used,  and  the  tartar  carefully  removed  from  the  teeth.  If 
the  bowels  show  irritability,  bismuth  and  catechu,  with  an  unirritating 
diet,  must  be  combined  with  the  mercurial. 

Such  a  course  will  save  most  mothers  from  miscarrying.  The  chances 
of  averting  the  mishap  are  greater  the  farther  removed  the  conception  is 
from  the  chancre.  Success  or  failure  in  one  pregnancy  must  modify  the 
treatment  of  the  next,  and  the  result  is  certain  to  be  finally  satisfactory 
to  all  concerned. 


230  THE    VENEREAL   DISEASES. 

Parents  who  have  lost  one  or  two  children  by  miscarriage  through 
syphilis  become  very  despondent,  and  the  mother  often  needs  considera- 
ble encouragement  to  induce  her  to  do  anything  for  a  given  pregnancy,  if 
former  trials  have  failed. 

There  is  no  objection  to  continuing  the  mercurial  treatment  up  to  the 
date  of  delivery,  diminishing  the  dose  during  the  last  month,  since,  presu- 
mably, if  the  child  has  gone  well  so  far  it  will  take  less  to  hold  it.  Sig- 
mund  thinks  the  mercury  should  be  stopped  with  the  seventh  month,  but 
there  does  not  appear  to  be  any  good  reason  for  such  a  course.  Milk  diet, 
combined  with  the  mercurial,  is  very  advantageous  in  pregnancy,  and  in 
any  case  a  mild  diuretic  should  be  occasionally  used. 


SYPHILIS    OF   THE   MAMMARY    GLAND.. 

Mention  has  been  made  of  the  possible  chancres  about  the  nipples,  and 
the  mucous  patches,  and  ulcers,  and  lesions  upon  the  skin  covering  the 
female  breast.  The  gland  itself  is  attacked  sometimes  by  syphilis.  Two 
forms  of  the  affection  have  been  observed — a  diffuse  mastitis,  and  a  gum- 
matous  infiltration. 

Diffuse  syphilitic  mastitis  is  very  rare.  It  has  only  been  observed 
apparently  in  the  secondary  period  of  the  disease,  and  is  encountered  in 
the  male  as  well  as  in  the  female  (Ambrosoli).  The  gland  simply  gets 
swollen  and  tense,  slightly  painful.  There  is  no  change  in  the  integu- 
ment, which  does  not  adhere  to  the  underlying  tissues.  No  special  treat- 
ment is  necessary.  The  swelling  always  goes  down  without  leaving  any 
trace  behind. 

The  gumma  of  the  breast  is  a  very  hard  swelling  occurring  on  one 
or  both  sides  without  pain.  It  goes  on  to  involve  the  skin,  softens  and 
discharges.  It  is  very  often  mistaken  for  cancer.  History  and  concomi- 
tant lesions  make  the  diagnosis,  and  the  iodides  in  large  doses  effect  a 
cure.  Gumma  of  the  breast  has,  been  observed  in  connection  with  in- 
herited syphilis. 


CHAPTER  XIV. 

SYPHILIS  OF  THE  EYE  AND  EAR. 

Syphilis  of  the  Eyelids  and  Conjunctiva. — Syphilis  of  the  Cornea,  the  Iris  (Plastic  and 
Gummatous  Iritis). — Syphilis  of  the  Vitreous,  of  the  Ciliary  Body,  of  the  Choroid, 
of  the  Retina  (Atrophy  of  the  Retina,  Retinitis  Pigtnentosa). — Syphilitic  Optic 
Neuritis. — Syphilis  of  the  Ear. — Syphilis  of  the  Outer  Ear  and  Auditory  Canal. — 
Plastic  Myringitis. — Syphilis  of  the  Auditory  Nerve. — Syphilis  of  the  Middle  Ear. 
— Ear  Affections  found  in  Inherited  Syphilis. — Catarrhal  Inflammation  of  the 
Middle  Ear,  Deaf -mutism. 

THE  skin  of  the  eyelids  is  occasionally  the  seat  of  chancre;  patches 
of  various  kinds  of  eruption  may  come  upon  it,  and  mucous,  flat  papules 
are  not  uncommon.  The  tarsal  borders  may  be  uniformly  thickened  in 
late  syphilis,  and  little  circumscribed  gummata,  looking1  like  styes,  but 
more  livid  and  painless,  are  quite  common  in  this  region  during  the  course 
of  the  malady. 

Upon  the  conjunctiva,  chancre  and  mucous  patches  have  been  ob- 
served. I  have  seen  a  case  of  indurated  chancre  of  the  caruncle  in  a 
female,  which  had  been  excised  on  account  of  a  diagnosis  of  epithelioma, 
but  induration  recurred  in  the  cicatrix,  and  general  syphilis  followed. 
Gummy  tumors  of  this  region  (the  lachrymal  caruncle)  is  quite  a  serious 
affection  in  appearance.  Dr.  R.  W.  Taylor,  of  this  city,  has  reported  * 
two  excellent  cases,  one  of  which  had  been  excised  for  cancer,  but,  return- 
ing, was  cured  by  iodide  of  potassium. 

The  lachrymal  sac,  and  the  skin  over  it,  may  be  the  seat  of  gummatous 
deposit,  and  if  this  be  allowed  to  ulcerate,  lachrymal  fistula  may  result. 
The  nasal  duct  is  frequently  occluded  by  reason  of  ulcerative  gumma- 
tous changes  of  mucous  membrane  and  bone  within  the  nasal  cavity,  es- 
pecially if  the  lachrymal  bone  be  involved  in  necrosis. 

Changes  in  the  cornea  are  very  uncommon  in  connection  with 
acquired  syphilis.  With  inherited  disease  chronic  interstitial  keratitis 
(Hutchinson)  is  quite  common.  It  will  be  described,  along  with  the  other 
lesions  of  inherited  syphilis,  in  Chapter  XV.  I  have  seen  one  well-marked 
case  of  chronic  interstitial  keratitis  due  to  acquired  syphilis  in  an  adult. 
This  patient  got  slowly  but  perfectly  well  under  a  mixed  treatment. 

The  iris  suffers  very  often  in  acquired  syphilis.  Mydriasis  and 
myosis  have  been  described  in  connection  with  the  affections  of  special 
nerves  due  to  syphilis. 

Iritis. — It  is  probable  that,  at  least,  half  of  all  the  cases  of  iritis 
which  occur  are  syphilitic  in  origin.  Iritis  most  often  comes  on  in  severe 
cases  of  syphilis  with  one  of  the  early  eruptions;  particularly  is  it  apt  to 
coincide  with  a  pustular  eruption.  The  symptoms  are  exactly  the  same 
as  those  of  acute  iritis  due  to  any  cause;  slight  dulness  and  change  in 
the  color  of  the  iris,  more  or  less  injection  of  the  peri-corneal  conjunctiva 

1  New  York  Medical  Record,  March,  1875. 


232  THE    VENEREAL   DISEASES. 

(possibly  chemosis),  lachrymation,  supra-orbital  pain,  generally  worse  at 
night,  and  intense  photophobia.  The  pupil  is  hazy,  and  will  not  dilate  in 
the  dark.  When  forced  to  dilate  by  the  use  of  atropia  or  duboisia,  its 
margin  is  often  festooned,  it  does  not  dilate  regularly.  Plastic  exudation 
of  lymph  is  quite  common,  effused  from  the  borders  and  posterior  surface 
of  the  iris  by  means  of  which  adhesions  are  effected  with  the  anterior 
capsule  of  the  lens,  and  the  dilatability  of  the  pupil  permanently  compro- 
mised. Its  opening  may  be  entirely  occluded.  A  thin,  diffused  plastic 
exudation  sometimes  tills  the  anterior  chamber.  It  may  seem  to  be  ab- 
sorbed and  to  melt  away  under  treatment. 

Gumma  of  the  iris  is  less  common,  but  may  be  observed  as  a  small, 
yellowish  red  papule  growing  from  the  iris.  This  may  reach  a  consider- 
able size,  fill  up  the  pupil,  and  distend  the  anterior  chamber.  It  may  be 
seen  to  disappear  under  the  internal  use  of  the  iodide  of  potassium.  In- 
stead of  growing  out  as  one  distinct  tumor,  there  may  be  several  small 
gummata  upon  the  iris,  or  the  whole  muscle  may  be  diffusely  infiltrated, 
and  contract  strong  adhesions  with  the  capsule  of  the  lens. 

The  ciliary  body  and  the  choroid  may  be  involved  in  inflammatory 
and  gummatous  complications  in  connection  with  syphilitic  iritis. 

Relapse  of  plastic  iritis,  especially  if  there  be  many  adhesions,  is  quite 
common,  and  these  relapses  may  continue  on  for  a  number  of  years,  a 
slight  cause,  such  as  over  use  of  the  eye,  the  influence  of  cold,  a  very 
bright  light,  being  sufficient  to  kindle  up  an  attack.  Plastic  iritis  is  often 
double,  simultaneously  or  consecutively.  Gummatous  iritis  is  generally 
confined  to  one  side. 

Treatment. — Iritis  generally  yields  a  very  prompt  obedience  to  the 
influence  of  mercury.  The  drug  may  be  given  in  any  shape,  but  it  should 
be  pushed  until  its  effects  are  quite  obvious.  If  the  patient  is  anfemic 
and  debilitated,  cod-liver  oil,  tonics,  change  of  air,  good  food,  etc.,  are  all 
of  the  highest  value.  No  care  should  be  spared  to  put  the  patient  under 
the  best  possible  dietetic  and  hygienic  surroundings,  for  an  important 
function  is  threatened.  The  mercury  should  be  pushed  until  the  gums 
show  its  influence  slightly. 

The  great  danger  in  iritis  is  adhesion  of  the  pupillary  margin  to  the 
anterior  capsule  of  the  lens.  If  this  occurs,  it  is  vastly  better  that  it 
should  do  so  with  the  pupil  widely  dilated;  hence  it  is  always  advisable 
to  use  instillations  of  solutions  of  atropia  or  duboisia  into  the  eye.  A 
solution  of  gr.  i. — iv.  to  the  3  i.  of  distilled  water  may  be  used;  a  few 
drops  being  placed  beneath  the  lid  once  a  day,  or  oftener,  if  it  is  found 
necessary,  in  order  to  hold  the  pupil  dilated  to  its  greatest  extent,  and 
this  should  be  continued  until  all  photophobia  has  passed,  and  all  conges- 
tion ceased.  If  atropine  irritates,  a  solution  of  duboisia,  the  new  mydria- 
tic,  may  be  used.  The  eye  should  be  kept  closely  shaded  from  light, 
but  it  is  not  wise  to  keep  the  patient  in  the  house,  much  less  to  confine 
him  to  a  dark  room.  Oleate  of  morphia,  or  the  oleate  of  morphia  with 
oleate  of  mercury,  may  be  rubbed  over  the  brow  in  case  of  pain — alone,  or 
combined  with  belladonna  ointment. 

The  gummatous  form  of  iritis  comes  most  readily  under  the  influence 
of  the  iodides,  but  the  use  of  atropia  is  desirable  in  these  cases  as  well  as 
in  the  plastic  form.  For  old  cases  where  the  pupil  is  adherent,  and  re- 
lapses occur,  iridectomy  is  the  remedy. 

The  vitreous  body,  from  degeneration  of  its  cells  and  proliferative 
changes,  may  show  opacities  caused  by  syphilis,  and  capable  of  removal 
by  treatment.  • 


SYPHILIS    OF   THE    EYE    AND    EAE.  2JJ 

Cataract  may  ensue  as  an  indirect  result  of  syphilis  due  to  disease 
in  the  choroid,  the  ciliary  body,  the  iris,  and  dependent  upon  opacities 
in  the  lens,  or  its  capsule.  Anti-syphilitic  treatment  will  not  relieve 
these  opacities,  and  the  result  of  operation  for  cataract  is  not  always 
satisfactory,  owing  to  possible  damage  occasioned  by  syphilis  in  the 
deeper  structures  of  the  eye. 

Cyclitis  has  been  observed  as  a  result  of  syphilis  and  gummata,  in- 
volving the  ciliary  body,  in  severe  cases  implicating  the  iris,  attended  by 
great  pain  and  calling  for  extirpation  of  the  globe  of  the  eye. 

The  choroid  may  be  affected  by  syphilis  alone,  or  in  connection, 
with  disease  in  other  structures  within  the  globe  ;  it  often  participates 
in  inflammatory  disturbances  which  primarily  involve  the  iris.  Syphilis 
does  not  seem  to  produce  changes  in  the  choroid  which  are  pathogno- 
monic.  Choroiditis  disseminata,  described  by  Graefe,  is  a  common  form  of 
the  disease  as  produced  by  syphilis.  'In  this  condition  the  ophthalmo- 
scope reveals,  through  a  clouded  vitreous  humor,  small  scattered  spots  of 
a  pale  color,  perhaps  with  reddened  borders  scattered  over  the  posterior 
surface  of  the  chamber  of  the  eye.  The  retinal  vessels  may  be  occasion- 
ally seen  unchanged,  passing  over  these  spots,  which  are  of  varied  size, 
but  never  large,  and  are  evidently  elevated  exudations.  The  optic  nerve 
is  congested. 

These  elevated  exudations  may  disappear  entirely  under  treatment, 
leaving  but  little  trace,  or  they  may  be  succeeded  by  small  white  atrophic 
spots,  without  pigment,  except  at  their  borders,  where  there  is  an  intensi- 
fication of  pigmentation  in  the  shape  of  a  dark  line.  The  vitreous  is 
more  or  less  clouded  with  opacities. 

This  disease  is  very  chronic  in  character,  not  attended  by  any  impor- 
tant symptoms,  so  far  as  the  general  health  is  concerned.  The  amount 
of  influence  upon  vision  is  proportionate  to  the  position  and  extent  of 
the  exudative  patches,  and  the  degree  of  atrophy  following  them.  The 
course  of  the  malady  is  very  chronic;  it  occurs  in  late  secondary  disease, 
and  well  along  in  the  tertiary  period.  Mercurial  treatment  is  appropriate, 
and,  unquestionably,  is  often  slowly  effective  of  much  good.  In  old 
cases,  where  atrophy  is  an  accomplished  fact,  or  far  advanced,  treatment 
is  of  little  or  no  value.  Local  treatment  is  useless.  The  eyes  should 
be  kept  protected  from  strong  light. 

The  retina  also  suffers  from  syphilis.  Both  eyes  may  be  attacked 
simultaneously  or  (most  often)  successively.  The  duration  of  retinitis  is 
variable;  sometimes  it  lasts  but  a  few  weeks,  but,  more  often,  is  chronic, 
lasting  several  months.  There  is  no  outside  redness  upon  the  conjunc- 
tiva, no  lachrymation,  no  pain,  moderate  photophobia.  The  only  subjec- 
tive symptoms  are,  in  the  beginning,  flashes  of  light;  later,  failure  of 
sight.  The  affection  may  get  well,  and  leave  little  or  no  trace,  or  may 
lead  to  permanent  impairment  of  vision. 

The  ophthalmoscope  reveals  a  cloudy  vitreous,  and  a  retina  apparently 
obscured.  Its  outlines  are  less  distinct  than  usual,  the  retina  is  oedema- 
tous,  the  retinal  vessels  are  hyperaemic,  as  well  as  the  optic  nerve;  the 
outline  of  the  papilla  is  not  clearly  marked.  The  veins  are  full,  and 
there  may  be  haemorrhages. 

There  is  a  form  of  syphilitic  retinitis,  which  Virchow  has  called  re- 
curring central  retinitis,  due  to  syphilis,  in  which  the  changes  are  pretty 
closely  confined  to  the  neighborhood  of  the  yellow  spot.  The  malady 
passes  off,  and  returns,  perhaps,  several  times. 

In  connection  with  atrophy  of  the  optic  nerve,  attending  syphilitic 


234  THE   VENEREAL    DISEASES. 

lesions  within  the  calvarium,  the  retina  may  also  atrophy.  Central  vision 
then  gradually  disappears,  and  defects  of  vision  become  evident  in  other 
parts  of  the  field.  Hughlings  Jackson  has  pointed  out  that  there  may  be 
evidence  of  considerable  engorgement  of  the  papilla,  by  the  ophthalmo- 
scope, for  some  time  before  vision  begins  to  fail  in  these  cases. 

Retinitis  pigmentosa  has  been  ranked,  by  Hutchinson  and  a  num- 
ber of  authors,  among  the  changes  of  the  eye  prevailing  in  inherited 
syphilis.  As  described,  it  appears  that  the  pigment  spots  are  scattered 
irregularly  over  the  fundus  of  the  eye;  the  choroid  is  involved,  amaurosis 
.comes  on  early,  and  the  progress  of  the  affection  is  rapid  (Swanzy).1 

The  treatment  of  syphilitic  retinitis  is  by  mercurials  in  moderate 
amount.  No  great  energy  of  treatment  is  called  for,  and  a  cure  may  be 
expected,  if  treatment  is  applied  during  the  early  stages  of  the  malady. 
Locally,  the  eyes  should  be  shaded  by  colored  glasses.  The  abstraction 
of  blood,  by  occasional  leeching  df  the  temple,  has  been  recommended. 

Optic  neuritis  is  an  affection  very  common  in  syphilis,  in  connection 
with  a  variety  of  lesions  of  the  brain.  It  may  also  originate  primarily 
within  the  globe  of  the  eye,  independently  of  external  causes.  It  is  very 
often  found  in  connection  with  convulsive  and  paralytic  changes,  due  to 
syphilis,  and  is  looked  upon  as  a  corroborative  symptom  of  great  value 
in  many  cases. 

The  symptoms  are:  diminution  of  the  field  of  vision,  in  one  direction 
or  another,  often  irregularly — a  portion,  perhaps  an  irregular  half  or  a 
quarter  of  the  field,  being  lost.  J.  Hughlings  Jackson  s  has  published  a 
case  of  intra-cranial  syphilis,  where  double  optic  neuritis,  due  to  cerebral 
gumma,  was  not  attended  by  any  evidence  of  impairment  of  vision. 
He  therefore  insists  upon  a  routine  examination  of  the  eyes,  with  the 
ophthalmoscope,  in  all  cases  of  nervous  disease  due  to  syphilis,  especially 
if  there  be  pain  in  the  head,  in  order  that  impending  optic  neuritis  may 
be  detected  early,  and  loss  of  sight  warded  off. 

In  simple,  light  cases  of  optic  neuritis,  the  ophthalmoscope  shows 
only  a  little  indistinct  blurring  of  the  papilla,  a  congestion  of  the  nerve, 
and  distention  of  the  central  vessels.  In  severer  cases,  the  disk  is  greatly 
swollen,  with  irregular,  obscured  borders.  The  disk  seems  infiltrated, 
and  is  of  a  cloudy  white,  or  grayish  red  color,  the  vessels  distended,  ir- 
regular, tortuous.  This  appearance  is  known  as  "choked  disk."  It  in- 
dicates intra-cranial  pressure,  as  by  a  tumor,  and  is  only  a  syphilitic 
symptom  by  coincidence.  It  occurs  equally  well  in  connection  with  tu- 
mors of  the  brain  due  to  other  causes.  Optic  neuritis  is  oftener  double 
than  single.  , 

The  treatment  of  optic  neuritis  is  the  mixed  treatment  of  tertiary 
syphilis  with  preponderance  of  the  iodides.  Local  measures  are  unneces- 
sary. The  effect  of  treatment  often  depends  upon  the  promptness  with 
which  it  is  commenced,  and  its  power  to  remove  the  intra-cranial  lesion, 
which  has  given  rise  to  the  trouble  in  the  eye.  The  eye-symptoms  are 
often  of  only  secondary  importance;  but  improvement  in  the  size  of  the 
field  of  vision,  and  an  arrest  in  the  progress  of  the  affection  may  be  often 
attained  by  suitable  treatment  persisted  in  for  a  considerable  time. 

1  Dublin  Quarterly  Journal,  Vol.  LI,  1861,  p.  294. 
1  Journal  of  Mental  Sciences,  July,  1874. 


SYPHILIS    OF   THE   EYE   AND   EAK.  235 


SYPHILIS    OF   THE   EAE. 

The  ear  suffers  in  various  ways  by  syphilis.  TJlcerative  and  bony  le- 
sions within  the  cavity  of  the  nose  and  the  pharynx  lead  to  thickening 
and  inflammatory  changes  in  the  Eustachian  tube  and  its  mucous  lining. 
These  may  terminate  in  catarrhal  troubles  of  the  middle  ear,  and  conse- 
quent impairment  of  hearing. 

The  external  ear  is  the  seat  of  many  cutaneous  lesions  and  ulcers  in 
syphilis;  mucous  patches  appear  sometimes  in  the  external  auditory  canal, 
and  a  peculiar  dry  scaliness  of  this  canal,  with  tendency  to  impaction  of 
cerumen,  is  quite  commonly  encountered  in  syphilitic  patients.  This  af- 
fection calls  for  constant  care  and  frequent  syringing  of  the  ear  to  keep 
the  passage  in  good  order  and  the  drum-head  clear  until  the  tendency  to 
dry  exfoliation  passes  away.  Improving  health,  when  the  depressing  in- 
fluence of  syphilis  has  been  removed,  restores  the  integument  of  the  audi- 
tory canal  to  its  normal  condition. 

There  is  an  inflammatory  condition  of  the  middle  ear  due  to  syphilis 
which  is  not  a  catarrh.  No  suppuration  occurs,  but  a  thickening  of  the 
drum-head  and  of  the  tissues  within  the  middle  ear  leading  to  a  restraint 
in  the  movements  of  the  ossicula.  It  is  a  sort  of  plastic  myringitis. 
Schwartze  and  Roosa  believe  that  this  condition  originates  in  a  periosti- 
tis of  the  middle  ear.  There  may  or  may  not  be  pain  as  a  subjective  con- 
dition in  this  affection.  The  hearing  is  always  more  or  less  impaired. 

The  treatment  of  this  affection  consists  in  the  employment  of  warm 
syringing,  the  application  of  leeches  behind  the  ear,  inflation  of  the  tym- 
panic cavity,  and  the  use  of  laxatives  and  diuretics.  The  mercurials  in- 
ternally are  generally  more  effective  than  the  iodides;  but  the  possibility 
of  implication  of  bone  calls  for  the  use  of  the  last-mentioned  remedy,  al- 
though not  in  very  large  doses. 

The  auditory  nerve,  the  second  branch  of  the  seventh  pair,  is  some- 
times the  seat  of  special  disease  in  syphilis,  aside  from  any  loss  of  function 
due  to  disease  of  the  bones  of  the  internal  ear  or  gummy  tumor  involving 
the  nerve.  Such  essential  loss  of  function  in  the  nerve  has  been  observed 
in  secondary  syphilis  by  Roosa,  who  found  it  could  be  greatly  improved 
by  internal  treatment.  In  tertiary  disease  it  sometimes  comes  on  suddenly 
without  warning,  not  attended  by  pain,  without  any  especial  symptoms 
except  that  the  patient  becomes  deaf — often  very  rapidly  so. 

If  the  cochlea  is  involved,  the  high  notes  of  the  musical  scale  are  lost 
first  (Roosa),  or  are  heard  double,  and  the  tuning-fork  on  the  forehead  is' 
heard  best  in  the  sound  ear.  Some  ringing  of  the  ear  is  complained  of, 
and  vertigo,  with  staggering,  are  apt  to  usher  in  the  disease. 

The  diagnosis  of  syphilis,  in  cases  of  deafness  coming  on  in  this  way, 
must  be  based  upon  the  history  and  concomitant  symptoms. 

The  treatment  must  be  energetic.     No  time  is  to  be  lost.     The  dis- 
ease should  be  taken,  if  possible,  at  its  very  beginning,  and  opposed  vig- 
orously with  specific  remedies  from  the  start.     Both  mercury  and  the  io- 
dide of  potassium  should  be  used,  and  both  should  be  pushed  rapidly.     If 
J  possible,  the  mercurial  bath  should  be  employed.     Two  drachms  of  the 
i  black  oxide  daily  in  a  vapor-bath  is  not  too  much  for  these  cases,  and  the 
iodide  of  potassium  should  be  commenced  in  ten-grain  doses,  largely  di- 
luted in  water,  after  each  meal.     The  quantity  should  be  slightly  increased 
at  each  dose  daily,  until  the  point  of  tolerance  has  been  reached.     Every- 
thing in  these  cases  must  be  made  subservient  to  the  treatment.     The  pa- 


236  THE    VENEREAL   DISEASES. 

tient  should  give  up  business;  he  should  have  his  mind  put  at  rest  and  be 
amused  as  much  as  possible.  He  should  be  confined  to  an  unirritating 
diet,  rice,  milk,  etc.,  with  bismuth,  if  necessary,  that  he  may  bear  his 
medicine  well,  and  the  medicine  should  be  pushed  to  the  point  of  toler- 
ance; for  with  this  disease  certainty  in  the  conviction  of  a  correct  diag- 
nosis and  vigorous  boldness  in  treatment  is  half  the  victory. 

In  inherited  syphilis  the  ear  suffers  in  two  ways.  There  may  arise, 
in  a  child  with  inherited  syphilis,  a.catarrhal  condition  of  the  middle  ear, 
which  is  very  obstinate,  and  likely  to  result  in  inflammatory  adhesions  of 
the  ossicula  and  permanent  impairment  of  hearing. 

Internal  mercurial  treatment,  with  cod-liver  oil,  and  plenty  of  suitable 
food,  constitute  the  best  measures  to  be  employed  against  this  affection, 
in  combination  with  change  of  air,  syringing  of  the  external  and  inflation 
of  the  internal  ear. 

Deaf-mutism  sometimes  occurs  in  children  with  inherited  syphilis 
who  have  been  born  with  perfect  capacity  for  hearing.  Jonathan  Hutch- 
inson  has  called  attention  to  a  loss  of  hearing  which  may  come  on  very 
suddenly,  sometimes  quite  slowly,  in  children  with  inherited  disease,  after 
they  have  begun  to  talk,  but  before  the  age  of  puberty.  This  affection  is 
apparently  an  essentially  nervous  malady,  not  attended  by  any  pain.  There 
is  no  evidence  to  prove  that  the  lesion  is  inflammatory.  Treatment  is  of 
little  or  no  value  in  these  cases,  and  their  pathology  is  not  understood. 


CHAPTER  XV. 

INHERITED   SYPHILIS. 

Syphilis  does  not  change  in  Type  during  Transmission  by  Inheritance. — The  Syphilitic 
Fretus. — Bone  Syphilis  in  Inherited  Disease. — Inherited  Syphilis  in  the  Infant. — 
Date  of  Appearance  of  Symptoms  in  Inherited  Disease. — Pemphigus  of  Inherited 
Syphilis. — The  Syphilitic  Countenance. — Syphilitic  and  Mercurial  Teeth.— Inter- 
stitial Keratitis. — General  Treatment  of  Inherited  Syphilis. 

SYPHILIS  may  be  transmitted  by  inheritance.  The  vexed  question  as 
to  whether  the  child  can  derive  its  disease  solely  from  the  father,  the 
mother  being  sound,  has  already  been  discussed  (p.  70),  as  well  as  the  possi- 
bility of  inheritance  in  the  third  generation.  There  can  be  no  possible 
doubt  that  active  early  syphilis  in  the  mother  necessitates  disease  in 
the  child,  if  haply  the  latter  come  to  term  at  all;  while  active  early  syph- 
ilis in  the  father  is  not  incompatible  with  a  healthy  child,  if  the  mother 
be  not  poisoned.  This  has  been  attested  by  numerous  well-observed  in- 
stances, from  a  variety  of  sources.  I  have  witnessed  it  on  two  occasions, 
which  do  not  admit  of  any  doubt  in  my  mind.  After  syphilis  becomes 
latent  in  the  parents,  when  they  both  appear  to  be  healthy,  the  child  may 
still  be  syphilitic,  and  repeated  successive  conceptions  may  all  yield  a  dis- 
eased product  for  a  number  of  years,  the  limit  of  which  cannot  be  defi- 
nitely stated  for  any  given  case.  This  much,  however,  seems  certain,  that 
the  rule  is  for  syphilis,  eventually,  to  wear  itself  out,  and  for  syphilitic 
parents,  no  matter  how  protracted  their  disease,  eventually  to  produce 
healthy  offspring,  provided  their  own  health  has  not  been  seriously  and 
permanently  undermined  by  syphilitic  cachexia  or  visceral  lesions.  In 
other  words,  syphilis  is  transmitted  only  as  syphilis.  Scrofula  is  not  syph- 
ilis. Debility  and  nervous  disease  in  children  is  not  syphilis.  A  syph- 
ilitic parent  may  produce  a  weakly  child,  because  she  has  had  her  own 
health  broken  by  syphilis;  but  she  would  have  produced  exactly  the  same 
child,  had  her  health  been  broken  by  want  and  privation,  by  cancer,  by 
malaria,  by  alcohol,  or  any  other  cause.  Syphilis  does  not  change  in  type 
by  transmission.  It  does  vary  greatly,  as  seen  in  the  child,  but  it  varies 
in  activity,  in  intensity,  not  in  type.  A  child  born  to  parents  in  active 
syphilis  is  not  apt  to  live  unless  its  own  vitality  has  been  sheltered  by 
the  treatment  of  the  mother  while  it  was  in  the  foetal  state.  A  child 
born  to  parents  whose  disease  is  on  the  wane,  perhaps  nearly  exhausted, 
shows  but  few  evidences  of  disease,  and  those  perhaps  only  during  ado- 
lescence; but  what  symptoms  it  does  show  bear  the  brand  of  syphilis,  and 
are  relievable,  if  at  all,  mainly  by  antisyphilitic  treatment. 

Syphilis  of  the  uterus,  ovaries,  and  placenta,  has  been  already  consid- 
ered (p.  226). 


238  THE   VENEREAL   DISEASES. 


THE   SYPHILITIC    FfETUS. 


When  the  intensity  of  syphilis  is  great  enough,  the  germ  is  incapable 
of  development  to  maturity,  and  the  foetus  dies.  This  death  of  the  pro- 
duct of  conception  may  be  attended  by  and  due  to  alterations  in  the 
placenta,  or  it  may  have  no  connection  with  such  changes.  The  ovum 
may  be  blasted  to  such  an  extent  that  abortion  of  a  misshapen  organized 
mass  occurs  within  a  few  months  after  conception.  The  sj'philis  of  the 
parents,  under  these  circumstances,  is  too  apparent  to  need  confirmation 
by  any  fresh  proof  drawn  from  any  condition  of  the  ovum,  and  the  latter 
is  hopelessly  damaged  from  the  start,  so  that  even  very  active  treatment 
of  the  mother  is  powerless  often  to  save  it  from  ruin.  Attempts  at  sav- 
ing the  fcetus  must,  however,  be  made  at  each  subsequent  pregnancy,  and 
the  chances  of  success  will  improve  very  materially  with  each  attempt. 

When  the  child  has  been  fully  formed,  and  then  dies  in  utero,  it  is 
very  uncommon  for  the  uterus  to  carry  it  to  full  term.  The  movements 
of  the  child  cease,  and  the  mother  may  feel  debilitated  without  being 
positively  sick,  or  she  may  retain  her  usual  health.  Under  these  circum- 
stances, even  if  the  death  of  the  fcetus  can  be  proved  by  a  cessation  of 
the  heart-sounds,  it  is  best  not  to  interfere  with  nature.  Nothing  is  to 
be  gained  by  bringing  on  premature  labor,  and  no  damage  likely  to  ensue 
by  leaving  the  dead  child  where  it  is.  The  labor  is  not  likely  to  be  un- 
natural in  any  respect.  The  mother  should  be  prepared  beforehand  for 
the  announcement  of  the  death  of  her  child,  and  measures  be  instituted 
early  to  suppress  the  flow  of  milk. 

When  a  fcetus  has  been  dead  in  the  uterus  for  some  time,  it  becomes 
macerated.  The  epidermis  raises  into  large  bullse  over  portions  of  the 
body,  or  sheds  off  entirely  in  large  patches.  The  amniotic  liquid  is  more 
or  less  cloudy,  discolored,  sometimes  putrid.  In  such  children  are  found 
invariably  certain  pathological  tissue-changes  in  the  viscera  and  in  the 
bones,  particularly  the  epiphyseal  ends  of  the  long  bones.  These  changes 
are  the  same  as  those  which  are  found  (although  less  marked)  in  the  vis- 
cera and  bones  in  children  who  die  of  inherited  syphilis  at  varying  periods 
after  birth.  The  visceral  changes  are  much  the  same  as  those  which  occur 
in  connection  with  some  cases  of  acquired  syphilis,  the  difference  being 
that,  with  inherited  disease,  visceral  lesions  are  much  more  common  than 
in  acquired  syphilis,  and  that  they  are  more  often  of  the  diffuse  intersti- 
tial type  than  gummatous,  as  distinct  tumors.  Interstitial  hyperplastic 
thickening  of  the  parenchyma  of  the  liver  and  lungs  is  very  common  in 
inherited  syphilis — so  common  as  to  be  the  rule  in  all  cases  dying  early. 
The  thymus  is  quite  constantly  involved,  and  the  spleen  and  kidneys  very 
often.  The  changes  in  these  organs  produced  by  inherited  disease  have  al- 
ready been  considered  in  connection  with  the  visceral  changes  produced  by 
acquired  syphilis.  It  is  unnecessary,  therefore,  to  repeat  them  here.  The 
changes  in  the  bones  in  inherited  syphilis,  however,  have  in  them  enough  of 
special  interest  to  demand  a  separate  description.  The  ordinary  necrotic 
and  carious  changes,  the  subperiosteal  gummata,  and  the  ulcers  involving 
the  bone,  already  described  for  acquired  syphilis  (p.  183),  occur  also  some- 
times in  children  with  inherited  disease  who  survive  ;  but  the  lesions  now 
about  to  be  studied  are  found  only  in  inherited  syphilis,  and  are  peculiar 
to  it.  They  are  very  constant  also,  and  it  is  said  may  always  be  found 
upon  any  dead-born  foetus,  if  the  cause  of  its  death  has  been  syphilis. 
All  children  "with  inherited  syphilis  do  not  necessarily  suffer  with  these 


INHERITED    SYPHILIS.  239 

bony  changes,  or  at  least,  if  they  do,  they  grow  up  without  bearing  any 
evidence  in  their  bones  that  they  have  so  suffered  ;  but,  if  the  syphilis  in 
the  inherited  state  be  intense  enough  to  blight  the  ovum  and  cause  the 
death  of  the  foetus,  then  these  bony  changes,  more  or  less  marked,  are 
constantly  found.  Parrot  states  that  the  changes  are  constant,  and  begin 
in  utero,  or  shortly  after  birth. 


BONE   SYPHILIS   IN   INHERITED   DISEASE. 

Much  has  been  written  of  late  years  upon  this  all-important  subject. 
Only  a  sketch  of  the  actual  conclusions  already  reached  can  be  given  here 
for  lack  of  space.1 

The  symptoms  of  bone  syphilis  in  inherited  disease  are  a  thickening 
at  the  ends  of  the  long  bones,  sometimes  involving  the  skin  in  inflamma- 
tory adhesion,  sometimes  attended  by  local  softening  and  suppuration, 
sometimes  having  gone  on  to  a  separation  of  the  epiphysis  from  the  shaft 
of  the  bone,  and  given  rise  to  an  inability  to  use  the  limb  (pseudo-paraly- 
sis, Parrot).  The  bones  most  often  diseased  in  the  order  of  their  relative 
frequency  are  the  long  bones  of  the  extremities,  the  ribs,  the  scapula, 
ilium,  cranium,  the  clavicles,  the  metacarpal  and  metatarsal  bones,  lastly, 
the  vertebrae.  The  lesions  are  nearly  always  symmetrical. 

The  changes  in  the  bones  take  place  at  the  line  of  cartilaginous  junc- 
tion between  different  centres  of  ossification,  and  are  most  marked  at  the 
epiphyseal  line  of  junction  at  the  ends  of  the  shafts  of  the  long  bones. 
Here  may  be  found  fusiform  swellings  thickening  the  bones  and  osteo- 
phytes,  bony  overgrowths,  which  may  be  felt  through  the  skin.  If  the 
degenerative  changes  have  advanced  far  enough,  an  epiphysis  may  be 
separated  from  its  diaphysis,  without  any  perforation  of  the  skin  or  dis- 
charge of  gummatous  material ;  or,  finally,  there  may  be  multiple  fractures 
of  the  bones  (rarely),  or  the  skin  may  become  adherent  and  perforated, 
allowing  the  debris  of  bony  and  cartilaginous  tissue  with  gummatous  ma- 
terial to  be  discharged  externally. 

All  of  these  conditions  (except  the  last)  may  be  found  in  children  dead- 
born,  and,  any  of  them,  during  infantile  life,  with  or  without  other  evi- 
dences or  of  syphilitic  disease.  They  should  be  sought  for  in  the  foetus 
dead-born  and  prematurely  delivered,  if  there  be  any  reason  to  suspect 
syphilis  in  the  parents. 

Another  morbid  condition,  due  to  syphilis  and  described  by  Parrot,  is 


1  Full  information  may  be  obtained  by  consulting  : 

Valleix :  Bull,  de  la  Soc.  Anatom.     Paris,  1834,  p.  169. 

Bargione  :  Lo  Sperimentale,  July,  1864. 

Wegner  :  Virchow's  Archiv,  Vol.  L. ,  p.  305. 

Waldeyer  and  Koebner  :  Virchow's  Archiv,  Vol.  LV.,  p.  367. 

O.  Haab:  Virchow's  Archiv,  Vol.  LXV.,  p.  366. 

Parrot :  Archiv.  de  physiol.  norm,  etpath.,  1872,  Nos.  3,  4,  and  5  ;  and  same  journal, 
1876,  No.  2,  p.  133 ;  also  Gaz.  des  hop.,  Sept.  25,  1877,  p.  881,  and  Gaz.  med.  de 
Paris,  No.  44,  1873. 

Taylor  :  Bone  Syphilis  in  Children.     N.  Y.,  1875. 

Porak:  Bull,  de  la  soc.  de  chir.,  Dec.  5,  1877,  p.  608. 

Polaillon  :  La  France  med.,  Nov.  4,  1877,  p.  701. 

Editorial  in  Brit.  Med.  Journ. ,  Oct.  13,  1877,  p.  530 ;  on  Communication  by  P.arrot 
to  Association  for  Advancement  of  Science  at  Havre. 


240  THE   VENEREAL   DISEASES. 

the  formation  of  osteophytes  in  the  anterior  fontanelle  of  the  growing 
child,  by  means  of  which  the  sutures  sometimes  become  ossified  and  the 
development  of  the  cranium  and  of  the  brain  interfered  with,  or  even  ar- 
rested. 

These  syphilitic  changes  in  the  ends  of  the  long  bones  may  require  the 
microscope  for  their  detection.  Often,  however,  the  changes  are  manifest 
to  the  unaided  eye.  The  thickening  at  the  end  of  the  bone  may  be  felt 
and  seen.  The  paralytic  symptoms  are  most  obvious,  the  child  will  not 
and  cannot  move  an  extremity.  The  perforation  of  the  skin  and  gumma- 
tous  discharge  can  be  seen  and  touched. 

On  cutting  into  the  bone,  the  morbid  line  between  the  epiphysis  and 
diaphysis  may  be  distinguished  as  a  reddened  or  grayish  yellow  band,  and 
the  prolongations  of  calcined  cartilage  can  be  seen  and  felt. 

It  is  possible  to  divide  the  minute  changes  into  three  degrees: 

In  the  first  degree  a  layer  of  osteophytic  growth  may  envelop  the 
bone,  sometimes  making  it  so  thick  as  to  double  its  diameter.  The  epi- 
physeal  cartilage  is  also  thickened.  The  cartilage-cells  become  hypertro- 
phied.  Increased  proliferation  takes  place  within  them,  and  the  cartilage 
becomes  prematurely  infiltrated  with  earthy  salts. 

In  the  second  degree  there  is  premature  calcification  of  the  intercellu- 
lar substance,  and  arrest  of  true  bony  formation. 

In  the  third  degree  there  is  softening,  and  inflammatory  changes  take 
place. 

The  exact  histological  nature  of  the  morbid  process  does  not  seem  to 
be  invariably  the  same,  although  the  changes  always  take  place  in  a  line 
between  the  proliferating  and  the  hypertrophic  zone  of  the  cartilage,  as 
shown  by  Haab.  This  author,  however,  believes  that  the  degeneration  is 
a  molecular  degeneration  of  the  cartilage  along  a  line  parallel  to  the  line 
of  ossification,  the  cartilage-cells  falling  into  the  molecular  change  and 
becoming  disintegrated,  after  previous  active  proliferation. 

Wegner  looks  upon  the  process  as  an  osteo-chondritis  beginning  in  the 
cartilage.  He  believes  that  the  vascular  supply  through  the  vessels  be- 
comes deficient,  through  a  too  rapid  deposit  of  bone-salts  on  the  one  hand, 
while  the  proliferating  cartilage-cells,  on  the  other  hand,  make  a  stagna- 
ting zone  between  the  proliferating  cartilage  and  the  medullary  spaces  of 
the  diaphysis. 

Waldeyer  and  Koebner  believe  the  process  to  be  the  formation  of  a 
syphilitic  granulation  tissue,  growing  out  from  the  medullary  prolonga- 
tions of  the  diaphysis  into  the  cartilage,  and  there  falling  into  softening 
which  leads  to  a  shedding  of  the  epiphysis. 

In  summing  up  it  may  be  said  that  the  changes  produced  in  the  ends 
of  the  long  bones  by  inherited  syphilis  take  place  through  the  ossifying 
zone  of  the  cartilage  and  the  sub-periosteal  tissue.  They  consist  in  hy- 
perostosis  and  calcification,  which  may  lead  to  permanent  thickening  of 
the  bone  without  softening,  or  may  be  active  enough  to  terminate  by 
softening  and  cellular  disintegration,  as  is  the  case  in  other  gummatous 
formations. 

The  pathognomonic  value  of  these  changes  in  the  ends  of  the  long 
bones  is  very  great,  since  no  one  has  yet  claimed  to  have  found  them  pro- 
duced by  a  cause  other  than  syphilis,  and  they  may,  therefore,  be  largely 
instructive  as  to  the  cause  of  death  in  obscure  cases,  where  repeated  mis- 
carriages take  place,  and  the  existence  of  syphilis  in  the  parents  is  not  on 
any  other  account  suspected. 

The  treatment  of  syphilitic  children  upon  whom  these  lesions  exist 


INHERITED    SYPHILIS.  241 

is  very  effective.  It  should  be  a  mixed  treatment,  mercury  being  used 
by  inunction,  and  the  iodide  of  potassium  given  internally  in  repeated 
doses  well  diluted,  commencing  with  a  very  small  dose  (half  a  grain  or  less 
for  an  infant)  and  increasing  it  steadily  but  slowly,  as  it  is  tolerated,  until 
a  dose  producing  an  obvious  effect  is  reached.  A  dose  somewhat  smaller 
than  this  maximum  dose  may  be  continued  for  some  months  after  the 
child  has  recovered  from  all  local  evidences  of  progressive  disease. 


SYPHILIS    IN   THE    INFANT. 

A  child  born  alive  with  inherited  syphilis  l  may  have  its  lungs  so  stiff- 
ened with  interstitial,  syphilitic,  cellular  changes  that  it  cannot  breathe 
sufficiently  to  support  life.  Its  liver  may  be  solid  with  parenchymatous 
changes,  and  it  may  grow  visibly  yellow  and  expire  in  a  few  days  or  weeks, 
without  any  especial  symptoms  on  the  skin  or  mucous  membranes. 

Digestion  may  be  interfered  with  by  the  induration  of  the  pancreas, 
which  Birch-Hirschfeld  2  found  to  be  so  common  in  his  autopsies  of  chil- 
dren dead  with  inherited  syphilis.  Occasionally  a  child  dies  in  convul- 
sions without  any  surface  signs  of  syphilis. 

Ordinarily,  however,  when  a  syphilitic  child  is  born  alive,  even  if  it 
happens  to  be  plump  and  fresh-looking  for  the  first  few  days,  very  char- 
acteristic changes  soon  begin  to  show  themselves.  The  face  grows  thin 
and  old-looking.  If  there  have  been  any  eruptive  phenomena  at  birth 
(excoriated,  papular,  scaly  patches),  these  increase  in  number  and  extent. 
If  the  skin  was  intact  at  birth,  it  begins  to  show  livid  patches,  which  run 
on  to  become  papular  or  pustular;  or  excoriations  of  livid  color,  and  cracks 
and  fissures  appear,  with  pimples,  boils,  abscesses,  and  other  lesions.  Con- 
dylomata  and  ulcers  at  the  anus  are  very  common.  The  skin  comes  off 
from  the  fingers  and  is  shed  from  the  palms  and  soles  in  large  patches  ; 
sometimes  the  nails  come  off.  Mucous  patches,  fissures,  and  ulcers  appear 
about  the  mouth.  Catarrh  involves  the  nostrils  and  the  child  gets  the 
snuffles,  the  nostril  caking-up  to  the  point  of  complete  obstruction,  so  that 
the  child  finds  it  difficult  or  impossible  to  nurse. 

Meantime,  the  voice  grows  husky,  hoarse.  The  child  cries  in  a  fright- 
ened, explosive  way,  or  moans  its  life  out  in  croaking  sobs.  Dry,  tearless, 
pitiful  crying  is  sometimes  the  method  the  poor  little  sufferer  takes  to 
announce  his  distress;  but  he  soon  becomes  marasmic,  and  death  cures 
him  of  his  pains. 

If,  by  careful  nursing  and  active  treatment,  he  pulls  through,  the  child 
may  become  marasmic  later,  or  be  stunted  in  his  growth,  perhaps  weakly 
in  constitution,  possibly  hydrocephalic.  During  his  early  life  he  may  have 
disease  in  his  bones,  ulcers,  gummata  in  different  positions,  ocular  trou- 
bles; indeed,  he  is  exposed  to  a  long  series  of  disorders,  which,  if  not  con- 
trolled by  antisyphilitic  treatment,  make  life  a  burden  and  lead  to  de- 
struction of  tissue,  to  deformity,  to  loss  of  function  in  various  important 
organs. 

On  the  other  hand,  a  child  may  entirely  recover,  and,  after  a  reason- 
ably prolonged  treatment,  grow  up  to  good  health  and  become  as  vigor- 

I  Acquired  syphilis  (for  example,  vaccinal  syphilis)  is  very  serious,  and  often  rapidly 
fatal  in  the  infant ;   but  it  is  similar  to  acquired  syphilis  in  the  adult,  in  that  the  vis- 
ceral lesions  only  come  on  after  a  longer  or  shorter  period  of  secondary  eruptions. 

II  Archiv  f.  Heilkund.,  Feb.,  1875. 

1G 


242  THE    VENEREAL    DISEASES. 

ous  as  any  one  else.  Such  children,  nevertheless,  may  have  syphilitic 
teeth  (p.  244),  and  be  stamped  with  the  syphilitic  countenance  for  life. 

The  date  of  appearance  of  syphilitic  symptoms  upon  children 
with  inherited  disease,  who  are  born  apparently  in  perfect  health  (as  often 
happens),  is  very  variable.  Statistics  taken  in  lying-in  hospitals  make  the 
most  common  period  about  the  second  three  weeks  of  life.  Occasionally 
children  grow  up  to  be  several  months  old  before  symptoms  show  them- 
selves, and  these  symptoms  may  be  quite  light  and  be  overlooked.  In 
such  cases,  when  tertiary  symptoms  come  on  quite  late  in  adolescence  or 
early  in  adult  life,  as  they  sometimes  do,  they  almost  invariably  receive 
the  cod-liver  oil,  iron,  etc.,  believed  to  be  of  value  in  scrofulous  complaints, 
and  much  important  time  is  lost  and  tissue  often  sacrificed  by  failure  to 
adopt  antisyphilitic  measures  in  time.  Fournier  has  a  case  where  inherited 
syphilis  appeared  at  the  age  of  25;  Zaulbaco  has  one  at  26;  Bulkley  one 
at  23,  and  another  at  24;  Dron  one  at  20.  I  have  now  under  observa- 
tion a  woman  of  22,  with  gummata  of  the  nose,  due  to  inherited  disease. 
Atkinson,  of  Baltimore,  has  called  attention  to  this  subject  in  an  excellent 
paper  upon  "  Late  Hereditary  Syphilis,"  in  the  American  Journal  of  Medi- 
cal Sciences,  January,  1879. 

This  possibility  of  the  appearance  of  lesions  due  to  hereditary  syphi- 
lis late  in  life  must  be  constantly  kept  in  mind,  or  mistakes  are  quite 
certain  to  be  made,  to  the  grave  detriment  of  the  patient. 


SYPHILITIC    PEMPHIGUS. 

Flattened  bullae,  varying  in  size  from  that  of  a  small  split-pea  to  that 
of  a  penny,  situated  upon  a  red  base  with  a  red  areola  and  containing  a 
thin  sero-pus,  are  sometimes  found  scattered  over  the  surface  of  syphili- 
tic children  at  their  birth,  or  coming  out  in  crops  shortly  after  birth. 
This  is  the  pemphigus  of  the  new-born  ;  it  is  nearly  always  syphilitic 
in  nature.  It  is  said  of  the  infantile  pemphigus  not  syphilitic,  that  it 
always  first  attacks  other  parts  of  the  body,  appearing  later  upon  the 
palms  and  soles,  while  true  syphilitic  pemphigus  starts  always  in  the  last- 
mentioned  localities,  and  may  indeed  remain  confined  to  them.  The  bul- 
ke  burst  and  show  excoriated,  livid  surfaces  beneath,  or  dry  up  into  green- 
ish yellow  crust. 

Children  so  intensely  syphilitic  as  to  have  this  eruption,  very  rarely 
recover  under  any  treatment.  Mercury  by  inunction  is  most  suitable. 


THE    SYPHILITIC    COUNTENANCE. 

Certain  physical  traits  of  countenance,  marked  more  or  less  strongly 
in  different  cases,  are  commonly  enough  encountered,  upon  growing  chil- 
dren with  inherited  syphilis,  to  be  considered  pathognomonic  of  the  dis- 
ease. They  constitute  what  Mr.  Hutchinson  calls  the  syphilitic  counte- 
nance, and  are  striking  enough  to  attract  attention  and  to  put  an  observ- 
ant physician  upon  the  track  of  syphilis  in  many  cases  before  he  has  asked 
the  patient  a  single  question.  A  child  with  inherited  syphilis  does  not 
necessarily  have  the  syphilitic  countenance.  Many  children,  unmistakably 
syphilitic  by  inheritance,  bear  no  marks  that  distinguish  them  from 
healthy  children.  One  child  in  a  family  may  be  marked,  and  all  born 
later  may  escape. 


INHEEITED    SYPHILIS. 


243 


In  a  child  somewhat  stunted  in  growth,  perhaps  looking  pinched  in 
all  its  physical  contour,  or  squared  and  dwarfed  in  stature,  generally 
with  an  abnormal  intelligence  running 
to  precocity  which  delights  its  parents, 
or  to  a  stolid  stupidity  suggestive  of 
idiocy — such  a  patient,  a  growing  boy 
or  girl,  without  any  positive  ulcers, 
or  nodes,  or  other  lesions  indicative  of 
syphilis,  will  be  found  often  to  have  a 
coarse  skin,  with  the  pores  more  marked 
than  usual.  His  color  will  not  be  ruddy, 
but  sallow,  dead-looking,  dry,  or  perhaps 
greasy.  His  face  will  look  flattened  out, 
rather  devoid  of  expression,  prematurely 
old,  grave,  perhaps  anxious.  His  fore- 
head is  rounded  and  prominent,  like  that 
of  a  hydrocephalic  child.  The  eyes  are 
often  small,  the  nose  undeveloped,  par- 
ticularly at  the  bridge,  which  remains 
broad  and  sunken  as  it  was  in  baby- 
hood. The  corners  of  the  mouth  are 
often  puckered  with  cicatrices,  repre- 
senting old  ulcers  at  the  angles  ;  other 
scars  may  mark  the  mucous  membrane 
lining  the  cheeks,  and  the  throat  may 
exhibit  the  ravages  of  past  ulceration. 
Such  a  child  is  apt  to  have  constant 
chronic  nasal  and  pharyngeal  catarrh. 
With  this  physiognomy  the  syphilitic 
teeth  are  apt  to  be  found,  and  marks 
of  old  iritis,  choroiditis,  or  interstitial 
keratitis,  and  more  or  less  deafness,  is 
rather  the  rule  than  the  exception. 

Fig.  22  (from  Maury's  Photograph- 
ic Journal)  represents  very  fairly  the  syphilitic  countenance,  together  with 
scars  of  ulcers,  nodes,  overgrown  and  irregular  bones,  and  the  general 
unlovely  shape,  of  a  girl  who  has  suffered  severely  from  inherited  syphilis. 


SYPHILITIC    AND    MERCURIAL   TEETH. 

Hutchinson,  in  his  Illustrations  of  Clinical  Surgery,  London,  1876  l  has 
described  and  figured,  with  copious  illustrations,  the  effects  of  syphilis  in 
modifying  the  shape  of  the  central  incisors  of  the  upper  jaw,  as  well  as 
the  changes  in  the  teeth  produced  by  the  use  of  mercury  during  their 
forming  stage.  Mercurial  teeth  are  very  often  found  in  the  mouth  along 
with  syphilitic  teeth,  and  the  mercurial  teeth  were  generally  considered 
to  be  also  syphilitic  until  Hutchinson  clearly  pointed  out  the  distinction 
between  them. 

The  true  syphilitic  "test  teeth,"  as  Hutchinson  calls  them,  are  the 
two  central  incisors  in  the  upper  jaw,  the  teeth  of  the  permanent  set. 
The  milk  teeth  do  not  show  this  typical  peculiarity  of  structure,  and  no 


Fasciculus  III. ,  Plate  xi. 


244  THE    VENEREAL   DISEASES. 

other  teeth  can  be  relied  upon  to  indicate  the  presence  of  hereditary  syph- 
ilis, excepting  the  two  above  mentioned.  The  first  set  of  teeth  may 
be  chalky,  and  fall  into  rapid  caries  ;  the  second  set  may  also  be  very  de- 
fective, falling  rapidly  into  caries,  some  of  them  stunted  in  growth,  some 
of  them  placed  crosswise  or  altogether  out  of  place  in  the  mouth  ;  but 
none  of  these  peculiarities  are  essentially  syphilitic.  On  the  other  hand, 
a  child  may  be  markedly  syphilitic  by  inheritance,  and  yet  its  teeth  be 
perfectly  sound. 

The  "  test  teeth  "  are  only  found  in  connection  with  inherited  syphilis. 
The  two  central  incisors  are  smaller  than  natural,  and  usually  converge 
somewhat  (Fig.  23,  from  a  cast  of  a  personal  case),  or  diverge  a  little. 

The  cutting  border  is  narrower  than 
the  base  of  the  tooth,  making  them 
peg-shaped,  and  along  the  lower  edge 
they  are  uniformly  notched  with  a 
single  broad  notch,  as  shown  in  the 
plate. 

These  single  broad  notches  are  the 
features    of    the    teeth    which    stamp 

Flo  23  them    as    syphilitic.       The    serrations 

at  the  cutting  border  of  the  incisor 
teeth,  produced  by  a  number  of  shallow  notches,  mean  nothing  so  far  as 
syphilis  is  concerned.  They  are  seen  not  infrequently  upon  all  the  inci- 
sors, of  the  lower  jaw  particularly.  Irregular  notches,  even  in  the  centre  of 
the  upper  central  permanent  incisors,  are  not  pathognomonic;  and  peg- 
shaped  teeth,  or  teeth  uneven  in  any  respect,  or  badly  placed  or  seamed  or 
discolored,  have  no  value  as  indicating  antecedent  syphilis.  The  "  test 
teeth,"  as  above  described,  are  caused  by  syphilis,  and  are  not  caused  by 
anything  else  so  far  as  has  yet  been  discovered.  The  cause  of  the  pecu- 
liar deformity  of  the  teeth  is  not  accurately  known.1  It  is  believed  to  be 
due  to  stomatitis  occurring  while  the  teeth  are  forming,  the  notch  being 
generally  due  to  a  chipping  away  of  the  edge  of  the  teeth,  which  edge  at 
first  is  very  thin. 

This  mechanism  of  the  formation  of  the  notch,  however,  is  not  uni- 
form, I  believe,  on  account  of  a  case  which  I  watched  from  an  early  age. 
The  notch  was  blunt  and  uniformly  smoothed  off,  covered  by  enamel. 
The  teeth  were  polished  white  and  perfect,  but  typical  in  their  general 
physiognomy.  Both  the  parents  of  the  child  had  syphilis,  and  she  her- 
self had  lost  her  soft  palate  at  an  early  age,  had  a  number  of  eruptions, 
and,  finally,  syphilitic  mania  and  gummata,  while  under  observation. 
This  child  came  under  my  observation  at  the  age  of  fourteen  years.  She 
is  now  twenty-two,  married,  and  the  mother  of  a  healthy  child.  Most  of 
her  teeth,  including  the  test  teeth,  are  smooth,  clean,  and  reasonably  white, 
and  the  notches  of  the  test  teeth  are  now  as  broad  and  smooth,  and  typi- 
cal as  they  were  when  first  observed. 

Generally,  when  the  edge  of  the  notched  tooth  is  thin,  it  chips  off, 

1  At  a  recent  meeting  of  the  London  Path.  Soc.,  Mr.  Hutchinson  showed  (Lancet, 
Dec.  6,  1879,  p.  837)  the  crown  of  a  milk  tooth  from  a  child  with  inherited  syphilis. 
Two  small  abscesses  formed  in  the  middle  line  of  the  gum  in  this  case,  over  the  cen- 
tral incisors,  from  which,  when  opened,  the  crowns  of  the  two  incisors  escaped.  Mr. 
Hutchinson  thought  that  this  case  helped  to  show  why  the  contra)  incisors  are  espe- 
cially affected  by  inherited  syphilis,  and  sustained  his  view  that  the  sacs  of  the  teeth 
are  inflamed  more  or  less  in  these  cases— this  accounting  for  the  defect.  He  had 
Been  a  case  similar  to  the  one  under  discussion,  once  before,  in  a  syphilitic  child. 


INHERITED    SYPHILIS.  245 

and  wears  down  with  advancing  life,  and  finally  loses  its  characteristic 
appearance. 

Mercurial  teeth  (Figs.  24  and  25),  according  to  Hutchinson,  illus- 
trate the  effect  of  the  excessive  use  of  mercury — of  mercurial  stomatitis 
upon  the  permanent  teeth.  The  teeth  most  plainly  marked  by  mercurial 
stomatitis  are  the  first  (the  anterior)  molars.  The  incisors,  all  of  them, 
and  the  canine  teeth  suffer.  The  bicuspids  escape.  The  mercurial  tooth 
is  deficient  in  enamel,  covered  with  ridges  and  spines  of  exposed  dentine, 
dirty-looking,  and  apt  to  become  promptly  carious.  Quite  often  only  the 
half  of  the  tooth  farthest  removed  from  the  gum  is  unhealthy,  the  half 
nearest  the  gum  preserving  its  enamel  in  a  smooth  and  reasonably  white 


FIG.  24.  FIG.  25. 


condition.  The  grinding  surface  of  the  molars  is  involved  in  the  affec- 
tion. Very  naturally  the  influence  of  mercury  is  also  often  shown  upon 
the  typical  syphilitic  teeth,  but  this  is  accidental,  and  by  no  means  essen- 
tial. 

Hutchinson  states  that  other  forms  of  stomatitis  may  also  produce  this 
change  upon  the  permanent  teeth,  but  it  is  more  marked  and  more  com- 
mon after  mercurial  stomatitis. 


INTERSTITIAL,   KEKATITIS. 

The  cornea  is  frequently  the  seat  of  a  chronic  interstitial  inflammation 
in  cases  of  inherited  syphilis.  The  affection  is  most  common  between  the 
ages  of  six  months  and  three  years,  most  common  of  all  during  second 
dentition,  but  may  be  observed  during  adolescence.  Occasionally  it  is 
encountered  in  acquired  syphilis. 

The  affection  comes  on  insidiously,  with  slight  peripheral  cloudiness  of 
the  cornea  advancing  toward  its  centre,  attended  by  moderate  photopho- 
bia and  more  or  less  of  a  peri-corneal  zone  of  subconjunctival  hyperasmia. 
Sometimes  the  symptoms  become  quite  intense.  The  cornea  gradually 
grows  quite  white,  and  sight  may  become  so  reduced  that  only  the  differ- 
ence between  light  and  darkness  can  be  perceived.  The  cornea  may  be- 
come soft  and  fluctuating  in  spots  by  diffuse  infiltration  of  pus.  Ulcera- 
tion  is  uncommon,  or  very  superficial  if  it  occurs. 

Gradually,  as  the  malady  gets  well,  the  whiteness  disappears  from  the 
periphery  toward  the  centre,  leaving  sometimes  clouded  spots  behind. 
The  iris,  the  choroid,  and  the  ciliary  body  may  be  involved  in  inflamma- 
tion during  the  course  of  the  disease. 

Both  eyes  may  be  involved  consecutively.  The  affection  in  each  eye 
lasts  from  a  few  months  to  more  than  a  year.  Relapse  is  possible. 


246  THE    VENEKEAL    DISEASES. 

Treatment. — Hygiene  and  dietetics  form  an  essential  part  of  the 
treatment  in  these  cases.  Cod-liver  oil,  tonics,  and  change  of  air  are  of 
great  service.  Treatment  by  mercurial  inunction  is  of  the  most  value,  or 
mild  internal  mercurial  preparation  may  be  used,  due  attention  being  paid 
to  the  digestion.  The  course  must  be  persevered  in  persistently,  with 
confidence  of  ultimate  success  in  preserving  vision,  if  the  general  health 
remains  good. 

Local  treatment  is  of  some  assistance,  but  not  so  valuable  as  the  gen- 
eral measures.  Warm  fomentations  in  the  beginning  of  the  affection  are 
strongly  recommended  by  Noyes,  and  instillations  of  a  solution  of  atro- 
pine  are  of  considerable  advantage,  especially  in  those  cases  in  which  the 
iris  is  threatened  or  involved  in  inflammation. 


TREATMENT    OF    INHERITED    SYPHILIS. 

In  the  chapter  upon  the  general  treatment  of  syphilis,  great  stress  was 
laid  upon  the  fact  that  mercury  was  a  natural  antidote  to  syphilis,  more 
or  less  useful  in  all  its  stages,  most  valuable  in  its  power  of  keeping  the 
disease  in  check,  and  very  certainly  possessed  of  ability  to  gradually  elim- 
inate the  disease,  and  retard  relapses  of  symptoms.  In  tertiary  forms  of 
syphilis,  however,  mercury  was  accorded  only  a  second  rank  among  reme- 
dies, the  preparations  of  iodine,  notably  the  different  iodides,  taking  the 
lead. 

In  inherited  syphilis  all  the  stages  of  the  disease  come  together,  as  it 
were.  The  child  is  born  already  permeated  through  and  through  with 
syphilis,  and  possessing  at  the  same  time  visceral  and  bony  changes  due 
to  tertiary  alterations  of  tissue  and  secondary  phenomena,  in  the  shape  of 
excoriations,  papules,  pustules.  The  discharges  from  many  of  these  lesions 
are  essentially  and  actively  contagious. 

In  inherited  disease,  notwithstanding  these  pathological  facts,  the 
iodides  can  usually  be  dispensed  with,  except  when  dealing  with  the  late 
lesions  of  adolescence  and  bone  lesions  occurring  during  childhood.  Com- 
monly, all  the  good  that  can  be  obtained  from  treatment  may  be  derived 
from  a  persistent  use  of  mercury,  not  pushed  to  the  extent  of  producing 
salivation. 

Salivation  is  very  difficult  to  produce  in  young  infants.  Excess  of 
mercury  given  to  them  generally  runs  itself  off  by  the  bowels.  Just  be- 
fore, and  during  the  period  of  second  dentition,  especial  care  is  necessary 
in  the  use  of  mercury,  in  order  to  avoid  causing  enough  stomatitis  to  give 
rise  to  mercurial  teeth. 

Mercury  is  introduced  into  the  circulation  of  syphilitic  children  pre- 
ferably through  the  skin.  The  only  obstacle  to  this  is  extensive  ulceration 
of  the  surface  (and  even  this  does  not  preclude  the  possibility  of  dusting 
the  skin  with  calomel),  or  the  existence  of  so  great  an  irritability  of  the 
integument,  that  the  local  use  of  mercury  cannot  be  borne.  This,  how- 
ever, is  exceptionally  uncommon.  The  advantage  of  administering  mer- 
cury by  the  skin  is  that  it  spares  the  child's  stomach  for  food.  At  no 
period  of  life  is  it  so  essential  that  the  stomach  should  be  unhindered  in 
the  performance  of  its  function  as  during  babyhood.  Another  excellent 
reason  for  employing  inunction  upon  babies  is,  that  it  is  often  impossible 
to  say  whether  they  get  enough  mercury  if  the  stomach  is  relied  upon, 
and  valuable  iime  may  be  lost  in  this  uncertainty.  Some  babies  vomit 
more  or  less  after  each  feeding,  and  are  constantly  regurgitating  between 


INHERITED    SYPHILIS.  247 

their  repasts,  and  whether  all  of  a  powder  or  potion  given  internally  stays 
down  or  not,  is  sometimes  a  matter  of  great  uncertainty. 

If  inunction  is  decided  upon,  from  five  to  twenty  grains  of  the  ten  or 
twenty  per  cent,  oleate  of  mercury  may  be  rubbed  daily  into  a  different 
part  of  the  child's  integument,  the  dose  being  regulated  by  the  intensity 
of  the  symptoms  and  the  age  and  vigor  of  the  child.  A  better  plan  than 
this,  and  one  the  infants  seem  to  prefer,  although  it  is  dirtier,  is  to  spread 
upon  the  flannel  belly-band  of  the  child  a  thick  patch  of  blue  mercurial 
ointment,  and  bind  it  against  the  integument,  removing  it  daily,  and 
washing  the  skin  well  with  warm  water  and  soap. 

If  any  eruption  or  mercurial  erythema  appears  at  the  site  of  the  mer- 
curial application,  a  new  spot  should  be  selected,  and  the  irritated  skin 
washed  with  a  delicate  toilet  soap  and  abundantly  powdered,  while  a  piece 
of  old  linen  should  be  worn  under  the  binder,  between  it  and  the  im- 
pending mercurial  eruption.  While  the  belly  is  recovering,  the  legs, 
thighs,  feet,  and  arms  may  be  used  for  inunction  or  for  the  continued  ap- 
plication of  ointment  upon  bandages. 

By  this  too  much  mercury  can  hardly  be  used.  As  soon  as  the  snuffles, 
the  eruptive  lesions,  and  the  restlessness  of  the  child  begin  to  mend  per- 
ceptibly, the  quantity  of  inunction  or  of  the  ointment  bound  upon  the  sur- 
face may  be  diminished;  but  the  treatment  must  be  kept  up  steadily  in  a 
mild  way  in  some  form  or  other,  certainly  as  long  as  through  the  period 
of  the  second  dentition. 

If  for  any  other  reason  it  is  deemed  advisable  to  use  mercury  internally 
instead  of  by  inunction,  the  gray  powder,  mercury  with  chalk,  is  a  prepa- 
ration sanctioned  by  long  usage.  This  may  be  administered  in  powder, 
commencing  with  a  sixth  to  a  quarter  of  a  grain  two  or  three  times  a  day, 
and  working  up  the  dose  rapidly  or  slowly  according  to  the  intensity  of 
the  symptoms,  until  the  latter  show  signs  of  yielding  or  the  bowels  are 
irritated  by  the  drug. 

In  the  latter  case  it  is  better  to  diminish  the  dose  or  to  substitute  in- 
unction, or,  in  some  cases,  where  a  continuance  of  a  large  dose  is  very  de- 
sirable, the  bowels  may  be  quieted  by  the  internal  use  of  mild  doses  of 
opium.  This,  however,  will  very  rarely  be  called  for. 

A  good  way  of  producing  a  rapid  effect  of  mercury  upon  a  child  is  to 
dissolve  a  half  grain  of  corrosive  sublimate  in  six  ounces  of  water,  and  to 
give  a  teaspoonful  of  this  hourly  for  the  first  day,  then  every  two  hours, 
finally  every  three  hours  or  at  longer  intervals,  unless  it  obviously  disa- 
grees. 

Indeed,  I  know  of  no  internal  preparation  which  agrees  better  with  an 
infant  than  a  solution  in  water  of  the  corrosive  chloride  of  mercury.  I 
have  used  it  in  various  other  disorders  as  well  as  in  syphilis,  and  I  think 
the  best  way  to  give  it  is  to  order  a  half-grain  of  corrosive  sublimate  to 
be  dissolved  in  six  ounces  of  water.  Each  teaspoonful  of  this  mixture 
contains  one  ninety-sixth  of  a  grain  of  the  drug,  and  is  a  fair  dose,  if  it  is 
frequently  repeated. 

This  watery  solution  has  absolutely  no  taste.  The  child  who  will  spit 
out  a  powder  will  take  this  solution,  believing  it  to  be  water.  The  medi- 
cine will  mix  with  milk  without  turning  it,  or  with  any  food  in  such  a  way 
that  its  presence  is  unsuspected;  and  if  the  whole  or  a  portion  of  a  given 
dose  should  be  regurgitated  by  an  infant,  it  is  not  a  very  serious  matter, 
since  the  doses  follow  each  other  in  such  quick  succession. 

I  have  not  yet  found  this  preparation  to  disagree  with  the  youngest 
infant.  The  average  interval  between  the  doses  has  been  three  to  four 


248  THE    VENEREAL    DISEASES. 

hours  for  prolonged  treatment,  the  intervals  being  shortened  when  a 
prompt  or  vigorous  mercurial  influence  was  desired.  Mercurial  stomatitis 
I  have  not  seen  accompany  the  use  of  this  remedy  in  this  way,  and  in- 
testinal disturbance  is  equally  uncommon — plenty  of  warning  being  given 
by  premonitory  symptoms  before  any  explosion  comes  on,  so  that  there 
is  time  to  avert  the  latter. 

Dr.  M.  A.  Wilson  experimented  with  this  treatment,  at  my  request,  upon 
a  number  of  infants  with  inherited  disease,  at  the  Out-Door  Department 
of  the  New  York  Foundling  Asylum;  while  Dr.  E.  R.  Chadbourne,  house 
physician  in  the  same  institution,  kindly  conducted  another  series  of  ex- 
periments for  me  in  the  same  direction,  upon  infants,  during  the  summer 
of  1879. 

Both  of  these  gentlemen  have  reported  favorable  results,  so  far  as  tol- 
erance of  small  doses  of  the  bichloride  by  young  infants  is  concerned,  the 
absence  of  any  irritating  or  evil  effect  of  any  kind,  and  the  prompt  influ- 
ence of  the  course  upon  the  cutaneous  lesions  of  inherited  disease. 

Many  cases  died,  as  they  do  under  all  treatment;  but  even  in  most  of 
these  the  visible  symptoms  seemed  to  be  favorably  modified  by  the  drug. 

The  cases  treated  by  Drs.  Wilson  and  Chadbourne  ranged  from  birth 
to  two  years  of  age,  the .  doses  of  mercury  from  the  y^  to  the  -fa  of  a 
grain.  The  intervals  between  the  doses  were  never  shorter  than  two  or 
longer  than  four  hours — average  three.  In  only  one  case  out  of  a  dozen 
experimented  on  did  any  gastric  or  intestinal  disturbance  come  on,  and 
this  was  promptly  allayed  by  lengthening  the  interval  between  the  doses. 

Iodide  of  potassium  may  be  administered  through  the  milk  of  the 
mother,  or  in  mild  doses  by  the  mouth  of  the  infant,  provided  the  dose 
be  given  with  the  food  and  be  itself  considerably  diluted  with  water. 

In  no  case  should  a  child  born  of  syphilitic  parents,  whether  it  shows  evi- 
dences of  inherited  disease  or  not,  be  allowed  to  suckle  a  healthy  wet-nurse. 
The  risk  of  infecting  the  latter  is  too  great  to  be  overlooked.  A  syphi- 
litic child  may,  however,  suckle  its  mother  with  advantage,  and  can  never 
infect  her  (Colles's  law),  even  although  s"he  be  considered  healthy  and 
has  never  shown  any  symptom  of  syphilis.  The  same  rule  applies  to  a 
wet-nurse.  A  syphilitic  woman  may  have  recovered  and  may  secrete  good 
milk,  and  such  milk  is  perfectly  suitable  for  the  child,  while  the  latter 
cannot  poison  the  nurse. 


PART  III. 
GONORRHCEA  AND  ITS  COMPLICATIONS, 


CHAPTEK  I. 

GONORRHCEA  IN  THE  MALE. 

Definition. — True  Gonorrhoea  is  not  acquired  by  Contact  of  the  Urethra  with  Pus  not 
in  itself  Gonorrhoeal. — Cases  illustrating  that  Urethral  Pus  does  not  always  pro- 
duce Gonorrhoaa  in  the  Female,  nor  Vaginal  Pus  in  the  Female  always  Gonor- 
rhea in  the  Male. — The  Causes  of  Urethral  Inflammation. — Symptoms  of  Urethri- 
tis  in  an  Unhealthy  Urethra  not  due  to  the  Contact  of  a  Virulent  Pus. — Symptoms 
of  Inflammation  in  a  healthy  Urethra,  due  to  Contact  of  Gonorrhoeal  Pus  or  other 
Irritating  Substance,  under  Circumstances  capable  of  generating  Urethritis. — 
Chordee. — Lymphangitis  of  the  Prepuce. — Spasmodic  Stricture. — Breaking  the 
Chordee. — Gleet. 

0 

GONORRHCEA  in  the  male  is  an  intense  urethral  inflammation,  charac- 
terized by  a  period  of  incubation,  and  by  a  profuse  discharge  of  pus 
which  possesses  virulent  qualities. 

This  definition  at  once  places  gonorrhoea  in  the  rank  of  virulent  dis- 
eases, a  position  not  accorded  to  it  by  some  writers  in  high  authority. 
Yet  it  is  impossible  to  see  why  gonorrhoea  should  not  be  called  virulent. 
It  has  a  period  of  incubation,  runs  a  course  of  varied  length,  possesses 
its  virulence  to  the  very  end,  and  is  in  the  highest  degree  contagious. 
These  are  the  qualities  to  which  syphilis  and  chancroid  owe  their  claim 
to  virulence,  and  why  should  the  title  be  denied  to  gonorrhcea  ? 
*-— *»Ihe  reason  for  taking  gonorrhcea  from  the  list  of  virulent,  and  pla- 
cing it  among  simple  diseases,  is  that  intense  urethritis  resembles  it  so 
closely  in  all  its  symptoms  that,  clinically,  a  diagnosis  between  them 
often  cannot  by  any  possibility  be  made.)  This,  however,  is  simply  due  to 
the  fact  that  the  symptoms  of  inflammation  of  the  urethra,  when  they 
run  high  (as  they  always  do  in  gonorrhoea),  are  alike,  whether  their 
cause  is  a  simple  or  a  virulent  one.  Theoretically,  a  distinction  must  be 
recognized  between  urethritis  and  gonorrhcea,  although  practically  such  a 
difference  oftentimes  cannot  be  demonstrated,  and  clinically  the  symp- 
toms of  inflammation  of  the  urethra  have  to  be  treated  symptomatically 
in  accordance  with  the  grade  of  their  intensity,  without  regard  to  the 
cause,  since  medicine  as  yet  knows  of  no  specific  for  gonorrhoea. 

There  are  many  reasons  for  maintaining  this  ground.  The  intensely 
contagious  quality  of  gonorrhoeal  pus  has  been  too  long  and  too  well 


250  THE    VENEKEAL   DISEASES. 

known  to  require  more  than  a  mention.  It  has  been  amply  demonstrated 
by  direct  experiment  (largely  by  French  investigators)  from  urethra  to 
urethra.  Rollet  refers  to  it  at  some  length.  It  has  been  demonstrated 
with  equal  certainty  by  oculists,  by  inoculation  of  the  conjunctiva  for 
clinical  purposes.  In  course  of  nature  it  is  often  disastrously  demon- 
strated upon  the  victim  who  has  exposed  himself  to  it  in  sexual  inter- 
course; and  the  eyes  of  a  patient  with  gonorrhoea  may  also  attest  the 
powerful  contagiousness  of  the  disease. 

No  one  can  possibly  dispute  the  fact  that,  if  pus  taken  from  a  case  of 
true  gonorrhoea  be  placed  upon  the  orifice  of  the  urethra  of  the  male,  or 
the  vagina  of  the  female,  an  inflammatory  disturbance  of  considerable 
intensity  will  be  lighted  up. 

On  the  other  hand,  it  cannot  be  denied  that  pus  of  the  most  varied 
character  (not  gonorrhoeal)  may  be  placed  upon  the  meatus  of  the  male 
urethra,  or  poured  along  its  course,  without  inflaming  the  canal.  In 
cases  of  intense  balanitis  beneath  a  very  tight  prepuce,  the  cavity  of  the 
foreskin  is  constantly  filled  with  dense  creamy  pus;  yet  in  such  a  case,  if 
the  foreskin  be  slit  up,  it  is  customary  to  find  the  glans  penis  excoriated 
in  patches,  and  the  meatus  of  the  urethra  raw  perhaps,  but  no  urethritis. 
Chancroid  sometimes  is  situated  within  the  very  lips  of  the  meatus,  and 
extends  a  certain  way  down  the  canal,  but  it  does  not  give  rise  to  gon- 
orrhoea. Pus  from  pyelitis  may  be  voided  as  thick  as  cream  through 
the  urethra,  but  it  does  not  occasion  inflammation  of  the  canal. 

In  the  female,  pus  from  the  kidney  or  bladder,  passing  through  the 
urethra,  pus  in  vast  quantities  coming  from  the  uterus,  pus  from  chancres, 
and  chancroids,  and  mucous  patches — none  of  these  kinds  of  pus  produce 
gonorrhoea  in  the  female. 

Finally,  the  male  may  often,  usually  in  fact  does,  cohabit  with  a 
female  whose  vagina  contains  more  or  less  pus  from  the  uterus,  and  re- 
main well;  while  in  many  ctees  a  man  with  a  more  or  less  purulent  dis- 
charge may  lie  with  a  woman,  and  she  will  remain  sound.  Not  so  in 
either  case,  however,  if  there  be  even  a  very  little  of  the  poison  of  gonor- 
rhoea in  the  case.  A  gleet  after  a  gonorrhoea  which  is  nearly  well  may 
give  a  gonorrhoea  to  a  woman,  and  a  small  amount  of  lurking  gonorrhoea 
in  the  vagina  may  easily  poison  the  male. 

Just  at  this  point  comes  in  all  the  difficulty  of  the  problem.  We  hear 
very  little  of  it  from  the  female  side.  A  large  percentage  of  men  in  cities 
have  a  small  amount  of  gleet  from  one  cause  or  another,  mostly  in  con- 
nection with  stricture;  yet  gonorrhoea  in  the  females  (their  wives),  with 
whom  they  cohabit,  is  far  from  being  common — it  is,  indeed,  very  excep- 
tional. In  France,  a  gleet  is  considered  a  natural  thing  with  a  soldier,  so 
much  so  that  it  is  called  the  "military  drop;"  but  the  women  with  whom 
they  live  are  not  phenomenal  in  having  any  analogous  disorder.  Indeed, 
there  are  certain  forms  of  urethral  discharge  which  seem  to  call  for  the 
married  state  for  their  cure,  which  get  well  during  regular  sexual  hygiene, 
and  do  so  without  involving  the  wife  in  any  disorder.  I  have  repeatedly 
sanctioned  marriage  while  a  patient  had  still  a  slight  amount  of  urethritis, 
which  would  not  get  well  because  he  was  engaged  to  be  married  and  was 
therefore,  perhaps,  constantly  suffering  from  ungratified  sexual  desire, 
due  to  stimulation  without  relief:  and  I  have  seen  the  happiest  result  fol- 
low such  a  marriage.  I  know  that  this  course  is  a  very  unsafe  one.  I  do 
not  recommend  it  as  a  rule  for  general  use.  1  distinctly  condemn  it.  It 
is  assuming  an  enormous  responsibility  to  tell  a  man  with  a  urethral  dis- 
charge to  marry  an  innocent,  virtuous  woman;  yet  it  must  be  done  some- 


GONOKKHCEA   IN    THE    MALE.  251 

times  after  deliberation,  and,  if  there  be  no  gonorrhoea  in  the  male,  the 
woman  is  perfectly  safe.  If  there  is  a  considerable  amount  of  pus,  a 
great  creaminess  in  the  urethral  discharge,  it  is  wise  to  postpone  marriage 
until  this  has  been  reduced;  but  an  urethral  discharge,  not  very  freely  pu- 
rulent and  not  dependent  upon  true  gonorrhosa,  does  not  disqualify  a  man 
from  marriage,  any  more  than  a  leucorrhoea  disqualifies  a  woman. 

This  point  is  such  a  delicate  one  that  I  am  constrained  to  dwell  upon 
it,  and  to  illustrate  it  by  the  recital  of  several  cases. 

A  gentleman  came  to  me  with  the  following  story.  He  had  been 
married  several  years  and  remained  true  to  his  wife.  He  went  abroad. 
Shortly  before  returning,  while  in  England,  he  fell  from  grace  on  one  oc- 
casion, several  days  before  going  aboard  ship.  He  felt  uneasy  during  the 
return  trip,  and  when  nearly  home  noticed  a  slight  mucous  moisture  in 
the  orifice  of  the  urethra,  upon  rising  in  the  morning.  After  returning 
home  he  feared  to  have  intercourse  with  his  wife,  and  his  discharge  be- 
came worse.  He  consulted  me.  I  found  that  his  discharge  was  mainly 
mucus,  although  quite  palpable  and  only  purulent  in  the  morning.  He 
had  had  a  former  gonorrhoea  in  youth.  I  concluded  that  gonorrhoea  was 
impossible,  since  more  than  two  weeks  had  passed  since  the  time  of  his 
exposure,  and  his  discharge  did  not  indicate  virulence.  I  therefore  told 
him  that  he  was  keeping  up  a  mild  urethritis  by  sexual  stimulation  with- 
out relief,  and  advised  immediate  renewal  of  relations  with  his  wife.  This 
prescription  was  faithfully  carried  out,  with  the  effect  of  prompt  relief  to 
the  urethral  discharge,  without  other  treatment. 

This  same  gentleman  came  to  see  me  after  another  European  trip;  but 
this  time  he  had  not  exposed  himself.  He  arrived  home  while  his  wife 
was  menstruating,  and  soon  found  that  he  had  a  slight  urethral  discharge 
something  like  what  had  troubled  him  so  much  before.  For  this  he  con- 
sulted me.  I  ordered  the  same  prescription,  and  cure  followed  at  once. 

Another  patient,  living  quietly  and  regularly,  performing  his  marital 
duties  without  exposure,  after  hard  work  in  a  cold  winter,  found  that  he 
had  an  urethral  discharge  which  was  quite  positively  purulent.  During  the 
treatment  of  this  he  ran  down  in  health,  became  rheumatic,  and  had  a 
perineal  abscess.  After  the  abscess  was  nearly  well,  while  the  urethral 
discharge  was  still  clearly  purulent,  although  getting  decidedly  thinner, 
he  resumed  his  sexual  relations  with  good  effect  and  without  damaging 
his  partner.  This  man  had  an  unhealthy  urethra  damaged  by  a  former 
gonorrhoea,  but  ordinarily  he  was  perfectly  well.  . 

I  have  repeatedly  been  consulted  by  men  with  an  urethritis  which 
yielded  some  pus,  who  were  married  and  in  constant  sexual  relations, 
which  they  stated  had  a  good  effect  upon  the  discharge,  the  wife  remain- 
ing well. 

A  very  striking  case  .is  the  following:  a  patient  of  mine  had  persistent 
purulent  gleet  of  several  years'  duration,  due  to  stricture  and  following 
gonorrhoea.  Under  hygienic  and  tonic  influences,  assisted  by  cutting  the 
meatus  and  using  a  very  large  steel  sound,  he  got  entirely  well.  He  con- 
tinued well  a  couple  of  years,  and  then  became  engaged  to  marry. 

While  waiting  for  his  wife  to  get  ready  he  became  overstimulated 
sexually,  and  visited  an  old  partner  on  one  or  more  occasions.  As  a  re- 
sult, apparently,  his  purulent  gleet  returned. 

For  this  I  treated  him  in  every  way  known  to  me  without  success.  I 
could  reduce  the  discharge  to  a  rather  profuse  mucous  gleet,  without  much 
creaminess  in  its  quality,  but  no  further.  I  cut  him  internally,  according 
to  the  modern  doctrine,  as  an  experiment,  to  which  he  consented,  until  his 


252  THE    VENEREAL   DISEASES. 

urethra  was  very  unnecessarily  large,  the  so-called  full  size  being  reached. 
The  effect  of  this  cutting  was  not  to  cure  the  gleet,  but  to  give  the  patient, 
at  the  site  of  the  incision,  a  hard,  fibrous  lump  in  the  roof  of  the  urethra, 
which  caused  his  penis  to  bend  painfully  upward  during  erection  for 
many  months.  Meantime  the  discharge  continued  unabated,  and  the 
patient  put  off  his  marriage  from  month  to  month. 

I  finally  became  convinced  that  there  was  no  poisonous  (gonorrhosal) 
quality  in  the  discharge,  if  there  ever  had  been  any,  and  I  urged  the  pa- 
tient to  marry,  since  the  hard  lump  in  the  roof  of  his  urethra  had  now  sub- 
sided, so  as  to  allow  an  erection  to  occur  without  pain.  But  marry  the 
patient  would  not,  being  afraid  of  poisoning  his  wife. 

I  therefore  took  him  to  see  in  consultation  a  well-known  specialist  in 
urethral  disease  in  this  city.  The  latter,  as  I  had  anticipated,  advised  that 
the  urethra  be  again  cut  internally.  This  I  declined  to  do,  and  asked  my 
patient  to  put  himself  under  the  charge  of  the  physician  whom  I  had  re- 
quested him  to  see  with  me.  The  patient,  however,  would  not  do  this 
unless  I  would  guarantee  a  cure;  and  this  I  could  not  conscientiously  do. 
His  discharge  of  pus,  therefore,  continued  thin  and  watery,  but  quite 
abundant;  and  his  future  wife  commenced  to  talk  of  discarding  him. 

I  now  absolutely  forced  this  man  to  marry.  I  took  all  the  responsibil- 
ity. Offered  to  do  everything  for  himself  and  for  his  wife  in  case  of  acci- 
dent, and  to  protect  him  from  her  censure.  Thus  I  finally  succeeded  in 
bullying  him  to  the  altar,  convinced  as  I  was  that  treatment  was  useless, 
and  that  the  man's  urethritis  was  kept  up  by  ungratified  sexual  desire. 

He  married  on  a  certain  day,  informing  me  the  day  before  that  he 
would  not  leave  town  after  his  marriage,  since  he  expected  both  that  he 
would  immediately  suffer  from  an  increase  in  his  discharge  and  that  his 
wife  would  become  poisoned. 

It  was  three  weeks  when  I  next  saw  him.  He  looked  fat  and  healthy, 
but  disturbed.  I  asked  him  how  he  had  been,  and  how  his  wife  was.  .She 
was  in  good  health,  and  his  urethral  discharge  had  ceased  shortly  after  his 
marriage.  But,  he  said,  it  is  all  coming  back  again.  I  am  beginning  to 
have  a  discharge,  and  to  feel  the  old  sensations  in  the  urethra  yesterday 
and  to-day.  I  asked  him  when  his  wife  had  begun  to  menstruate.  He 
replied,  "  The  day  before  yesterday." 

What  can  be  more  strikingly  illustrative  of  the  effect  of  sexual  hy- 
giene upon  an  urethral  discharge  than  this  case?  I  told  the  man  to  do 
nothing,  and  that  he  would  again  recover  shortly  after  his  wife  had  ceased 
menstruating,  and  that  when  he  became  sexually  calmer  he  would  not 
suffer  during  the  monthly  sickness  of  his  partner.  He  went  away  contented, 
and  has  never  been  a  patient  of  mine  since.  I  met  him  upon  the  street 
about  two  years  afterward.  He  looked  well,  and,  in  response  to  my  ques- 
tion, said  that  he  was  perfectly  well,  and  that  his  wife  had  presented  him 
with  a  fine  boy. 

It  is  possible  to  multiply  instances  of  this  sort  without  limit,  but  enough 
has  been  said  to  show  that  an  urethral  discharge  in  the  male  does  not  neces- 
sarily produce  gonorrhoea  in  the  female.  If  the  discharge  in  the  male  be 
the  tail  end  of  a  gonorrhoea,  however,  then  the  woman  is  fortunate,  in- 
deed, if  she  escapes  contagion. 

Finally,  as  to  the  power  of  pus  in  the  vagina  to  give  gonorrhoea  to 
the  male.  Doubtless  the  male  often,  and  most  often,  indeed,  gets  his 
urethritis  from  contact  with  such  irritating  discharges,  but  he  does  not 
necessarily  become  irritated  by  them  at  all.  Indeed,  he  usually  escapes, 
unless  his  o\vn  urethra  has  been  damaged  by  previous  gonorrhoea,  and  he 


GONOREHCEA    IN    THE    MALE.  253 

happens  to  be  himself  either  debilitated,  overtired,  or  full  of  liquor,  or 
suffering  coincidently  from  very  acid  urine,  or  unless  he  overstimulates 
himself  sexually.  All  of  these  causes  are  capable  alone  of  producing 
urethritis;  each  of  them  separately  may  do  it,  as  recorded  cases  attest; 
even  intense  sexual  excitement,  much  prolonged,  without  any  sexual 
contact  at  all,  and,  a  fortiori,  if  the  local  influence  of  irritating  discharges 
lends  a  helping  hand. 

When  a  patient,  however,  offers  himself,  in  sexual  exposure,  to  the 
poison  of  true  gonorrhoea,  he  is  certain  to  become  poisoned  without  the 
cooperation  of  any  of  the  adjuvants  mentioned  above.  A  simple  expos- 
ure is  enough.  The  result  is  quite  certain,  and  very  evident. 

The  theoretical  distinction,  therefore,  between  gonorrhoaa  and  ure- 
thritis is  clear;  the  clinical  distinction  is  often  equally  so.  Yet,  without 
doubt,  an  intense  urethritis  is  one  and  the  same  in  its  symptoms,  whether 
its  cause  be  gonorrhoeal  virus  or  any  other  irritating  internal  or  external 
cause;  and  the  treatment  of  intense  urethritis  is  the  same,  whether  its 
cause  be  virulent  or  otherwise. 

Cause. — From  what  has  already  been  written,  it  may  be  inferred  \ 
that  the  causes  of  urethral  inflammation  are  quite  varied.  The  cause  of 
true  virulent  gonorrhoea  is  single,  namely,  contact  of  the  affected  person 
with  gonorrhoeal  pus  from  another  person.  Urethritis,  however,  may  be 
produced  in  a  variety  of  ways  almost  infinite,  and  it  cannot  be  distin- 
guished in  its  symptoms,  when  intense,  from  a  gonorrhoea.  This  fact 
cannot  be  too  often  repeated.  That  surgeon  is  bold  indeed,  who,  in  face 
of  a  certain  urethral  discharge  of  given  intensity,  will  pronounce  upon  its 
origin  with  any  confidence.  No  one  can  be  accused  of  impure  relations 
because  he  has  a  profuse  urethral  discharge.  It  cannot  even  be  said  that 
such  a  person  has  had  sexual  intercourse  at  all;  for  it  is  possible  for  a 
man,  virgin  of  all  venery,  to  have  an  intense  urethral  inflammation,  and 
much  injustice  may  be  done  by  accusing  him,  on  the  one  hand,  or,  on  the 
other,  of  accusing  his  partner — if  he  has  had  one — of  having  given  him 
a  disease. 

The  moral  is,  that  the  physician  is  not  a  judge.  His  function,  if  he 
has  any  of  the  judicial  sort,  is  to  shield  the  innocent.  He  should  accuse 
no  one,  but  confine  himself  to  his  own  proper  duties,  and  treat  the  symp- 
toms of  the  patient. 

If  the  urethra  is  healthy,  it  does  not  easily  become  inflamed,  except- 
ing by  contact  with  gonorrhoeal  pus.  Yet,  a  healthy  urethra  does  some- 
times suppurate  after  mechanical  violence,  such  as  the  rough  introduction 
of  instruments  through  it;  after  chemical  violence — the  injection  of  irri- 
tating substances  for  experiment,  or  under  the  idea  of  employing  a  pro- 
phylactic against  supposed  infection.  A  healthy  urethra  may  also  be- 
come inflamed  by  the  combined  influence  of  venereal  excitement — espe- 
cially if  intense  or  prolonged — and  contact  of  an  irritating  discharge,  leu- 
corrhoeal  pus,  menstrual  blood,  etc. 

An  unhealthy  urethra  is  always  ripe  and  ready  for  inflammation.  In 
strumous,  strongly  lymphatic,  gouty,  and  rheumatic  subjects,  the  urethra 
seems  prone  to  take  on  inflammation  easily,  especially  if  the  person  be 
cachectic,  overworked,  or  at  all  reduced  in  general  health  from  any 
cause.  In  such  cases  the  mucous  membranes  generally  are  apt  to  be  in 
an  irritable  condition,  and  to  take  on  subacute  inflammation  from  trivial 
causes. 

When  the  urethra  is  actually  diseased,  on  account  of  the  previous  ex- 
istence in  it  of  acute  inflammation — when  it  contains  a  thickened,  hyper- 


254  THE   VENEREAL   DISEASES. 

jemic  patch,  constituting  a  slight  stricture — then  it  is  in  a  prime  condi- 
tion to  be  irritated  into  suppuration — often  a  suppuration  of  formidable 
proportions  —  by  causes  which,  in  a  healthy  urethra,  would  fail  of  pro- 
ducing any  obvious  result.  This  is  especially  true  when  the  urethra, 
besides  being  the  seat  of  a  chronic  patch  of  congestion  left  behind  by  an 
old  gonorrhoea,  is,  at  the  same  time,  diathetically  unhealthy,  owing  to 
the  broken  health,  the  bad  hygienic  surroundings,  the  cachectic  condi- 
tion, the  nervous  prostration,  or  the  scrofulous  or  gouty  constitution  of 
the  patient. 

When  the  urethra  is  unhealthy,  the  introduction  of  a  sound  will  some- 
times produce  quite  a  sharp  attack  of  urethritis.  The  passage  of  very 
acid  urine  through  the  canal  may  bring  about  the  same  result,  whether  the 
uric  acid  crystals  be  due  to  indigestion,  an  attack  of  gout,  or  over-stimu- 
lation by  alcohol  (particularly  beer  or  champagne).  Mere  excess  of  sexual 
excitement  will  sometimes  produce  a  flow  of  pus,  and  prolonged  sexual 
intercourse  may  do  the  same,  particularly — and  this  is  one  of  the  most 
active  causes — if  there  be  any  irritating  discharge  in  the  vagina.  In  early 
married  life  the  male  is  not  unlikely  to  get  a  little  urethritis  from  his 
wife  ;  but  after  his  approaches  become  less  amorous,  he  has  no  further 
trouble. 

In  connection  with  many  morbid  states  of  the  prostate  (cancerous, 
tubercular,  inflammatory),  and  of  the  urethra  (herpetic,  chancrous — in 
deep  urethra,  tubercular,  syphilitic)  a  more  or  less  purulent  flow  from  the 
urethra  may  be  encountered,  and  a  purulent  discharge  dependent  upon, 
organic  stricture  is  of  every-day  occurrence. 

Symptoms. — In  studying  the  symptoms  of  inflammation  of  the  ure- 
thra, it  will  be  convenient  and  practical  to  make  two  classes  of  cases,  and 
briefly  to  review  the  symptoms  in  each. 

Symptoms  of  urethritis  of  an  unhealthy  urethra,  not  due  to 
the  contact  of  a  virulent  pus. — This  is  by  far  the  commonest  form  of 
urethritis.  This  is  the  form  which  those  people  have  who  say  they  have 
had  a  dozen  cases  of  gonorrhoea,  and  of  those  boasters,  who  claim  that 
they  get  the  gonorrhoea  constantly,  but  that  they  do  not  mind  it,  as  they 
have  a  little  injection  which  cures  it  up  in  three  or  four  days.  In  this 
form  the  patient  gives  himself  the  disease  much  more  than  his  partner 
gives  it  to  him.  He  has  a  damaged  patch  of  mucous  membrane  within  his 
urethra,  and  any  one  of  a  number  of  exciting  causes  is  sufficient  to  kin- 
dle the  slumbering  congestion  into  an  active  discharging  inflammation. 

In  these  cases  the  discharge  originates  at  a  certain  distance  within 
the  urethra  from  the  very  start.  It  does  not  commence  at  the  meatus. 
The  patient  has  intercourse  perhaps  with  a  woman  who  has  no  gonorrhoaa 
— who  at  most  has  a  purulent  leucorrhcea.  In  twenty-four  to  forty-eight 
hours  he  presents  himself  to  the  physician  for  inspection,  stating  that  he 
has  an  attack  of  gonorrhoea. 

Inspection  now  shows  that  the  lips  of  the  meatus  urinarius  are  not  in 
the  least  swollen.  The  attack  manifestly  has  not  begun  at  the  meatus. 
The  lips  of  the  urethral  orifice  still  show  the  livid  line  so  often  seen  when 
there  is  stricture  in  the  course  of  the  canal.  The  discharge  is  thick  and 
purulent  from  its  very  start.  There  is  little  or  no  itching,  or  tingling, 
along  the  course  of  the  urethra.  There  is  some  heat  and  smarting  in  the 
urethra  during  the  urinary  act,  but  very  little  discomfort  between  times. 

A  discharge  starting  in  this  way  is  not  a  gonorrhoea  ;  but  it  may  go  on 
and  assume  all  the  quality  of  the  most  intense  urethral  inflammation,  ac- 
companied by  any  of  the  complications  of  ii;  >JK in'iu-a.  and  absolutely  in- 


GONOKRHCEA    IN   THE    MALE.  ZOO 

XV 

distinguishable  from  it  clinically  ;  or  it  may  subside  in  a  few  days,  or,  at 
most,  weeks,  under  moderate  symptomatic  treatment,  and  give  very  little 
discomfort.  The  latter  termination  is  by  far  the  more  common. 

Symptoms  of  inflammation  in  a  healthy  urethra  due  to  con- 
tact of  gonorrhceal  pus,  or  other  irritating  substance,  under  cir- 
cumstances capable  of  generating  urethritis. — Urethritis,  under 
these  circumstances,  always  commences  at  the  meatus.  If  the  cause  has 
been  inoculation  with  gonorrhoeal  pus,  there  is  always  a  period  of  incuba- 
tion between  the  moment  of  exposure  and  the  outbreak  of  the  first  symp- 
tom. This  incubation  period  is  usually  from  five  to  eight  days.  When, 
however,  the  cause  is  some  irritating  discharge,  not  gonorrhoeal,  com- 
monly the  evidences  of  commencing  irritation  at  the  meatus  appear  on  the 
second  day  ;  sometimes  they  are  delayed  up  to  the  fourth,  or  even  sixth, 
but  rarely  any  longer.  .- 

The  first  symptom  in  these  cases  is  an  osdema  of  the  meatus,  which 
makes  the  lips  of  the  urethral  orifice  pout.  This  swelling  may  be  insigni- 
ficant in  urethritis;  it  is  invariable  in  gonorrhoea.  The  color  of  the  orifice 
of  the  urethra  is  pink  rather  than  blue.  The  patient  feels  a  sensation  as 
though  a  hair  had  been  caught  in  the  meatus  and  was  being  drawn  through 
it.  There  is  a  sensation,  varying  between  a  tickling  and  an  itching,  which 
is  quite  apt  to  be  complained  of,  either  at  the  very  meatus  or  at  a  point 
about  three-quarters  of  an  inch  within  the  urethra,  upon  its  under  side. 
These  sensations  keep  the  patient's  mind  fixed  upon  his  genitals,  and  call 
upon  him  to  empty  his  bladder  rather  more  frequently  than  usual.  The 
passage  of  urine  over  the  tender  ends  of  the  urethra  causes  a  hot,  stinging 
pain,  an  ardor  urinag,  more  or  less  intense,  in  different  patients. 

Between  the  lips  of  the  pouting  meatus,  perhaps  faintly  sealed  with 
dried  mucus,  a  drop  of  watery  pus  is  seen  at  all  times  during  the  first 
twenty-four  hours.  On  the  second  day  this  drop  becomes  more  creamy, 
and  all  the  disagreeable  sensations  increase,  while  from  day  to  day  the 
discharge  becomes  more  copious  and  more  purulent. 

During  the  second  week  the  pus  from  the  urethra  assumes  a  green 
tint,  due  to  slight  admixture  with  blood,  and  all  the  symptoms  intensify, 
unless  the  discharge  turns  out  to  be  a  mild  urethritis,  in  which  case  it 
sometimes  reaches  its  height  during  the  first  week,  and  commences  to  de- 
cline during  the  second.  This  it  never  does  if  it  is  true  gonorrhoea. 

Chordee. — If  the  inflammation  runs  high  at  the  end  of  the  second  and 
during  the  third  week,  erections  become  painful.  The  inflammation  does 
not  remain  confined  to  the  surface  of  the  urethral  membrane,  but  works 
down  through  the  minute  ducts  into  the  mucous  glands  of  the  urethra, 
and  spreads  from  thence  to  the  delicate  meshes  of  the  spongy  tissue  of 
which  the  corpus  spongiosum  is  composed.  These  meshes  of  tissue,  be- 
coming stiffened  and  agglutinated  together  by  the  inflammatory  process 
over  a  given  (usually  limited)  area,  no  longer  allow  themselves  to  become 
distended  by  the  influx  of  blood  which  occurs  during  erection.  As  a  con- 
sequence, when  the  rest  of  the  penis  is  distended  with  blood,  and  only  a 
limited  portion  remains  empty,  the  empty  part,  being  relatively  too 
short,  draws  together  the  distended  parts,  acting  like  a  cord  to  a  bow,  and 
the  penis  becomes  curved,  its  point  of  greatest  concavity  corresponding 
to  the  inflamed  area  of  corpus  spongiosum.  The  inflammation  often  does 
not  run  so  high  as  to  obliterate  the  meshes  of  the  corpus  spongiosum,  but 
renders  them  sensitive  when  dragged  upon.  In  such  a  case  there  will 
be  a  painful,  perhaps  hard  spot  in  the  urethra  upon  erection,  but  no  bend- 
ing of  the  penis. 


256  THE    VENEREAL    DISEASES. 

This  bending  of  the  penis  is  called  chordee.  Painful  erections  are 
very  common  during  the  third  week  of  a  gonorrhoea,  and  from  that  date 
onward  until  the  discharge  has  ceased.  Sometimes  erections  still  continue 
to  be  somewhat  painful  after  the  flow  of  pus  has  entirely  disappeared. 

During  the  second  or  third  week,  in  some  cases,  the  prepuce  becomes 
implicated  in  inflammation.  This  is  due  to  a  lymphangitis,  generally  of 
the  smaller  lymphatic  vessels.  As  a  result  the  foreskin  may  swell  enor- 
mously, and  become  white  with  oedema,  and  this  oedema  may  go  on  to 
involve  the  whole  penis.  It  frequently  leads  to  paraphymosis,  when  the 
prepuce  is  short.  If  the  very  finest  lymphatics  are  the  seat  of  the  inflam- 
mation, the  prepuce  swells,  but  is  red,  hot,  erysipelatous,  there  is  com- 
paratively little  oedema,  the  tissues  of  the  prepuce  are  inflamed  and  stiffened 
with  inflammatory  exudation.  If  the  prepuce  be  long,  phymosis  is  apt  to 
occur,  and  occasionally  the  inflammation  runs  on  to  the  extent  of  produ- 
cing abscess  between  the  layers  of  the  prepuce. 

When  the  prepuce  is  tight,  although  it  may  not  become  inflamed  in 
its  own  texture,  yet  if  the  gonorrhceal  discharge  is  not  kept  carefully 
washed  out  of  its  cavity,  the  pus  is  apt  to  be  retained  in  the  furrow  be- 
hind the  glans  penis,  and  there  becoming  decomposed,  to  give  rise  to  bal- 
anitis  and  posthitis,  and  to  lead  to  the  formation  of  innumerable  warts, 
the  so-called  venereal  warts,  which  are  always  apt  to  be  produced  by  un- 
cleanness  beneath  the  prepuce. 

As  the  inflammation  extends  backward  within  the  canal  of  the  ure- 
thra, the  deep  urethral  muscles  are  apt  to  be  thrown  into  spasm,  which 
leads  to  dribbling  of  urine  and  difficulty  in  voiding  the  contents  of  the 
bladder.  Sometimes  actual  retention  comes  on,  usually  only  in  connec- 
tion with  active  inflammatory  congestion  of  the  prostate  and  cystitis  of 
the  neck  of  the  bladder.  Abscess  of  the  prostate,  peri-urethral  abscess, 
perineal  suppuration,  inguinal  glandular  abscess,  are  among  the  possible 
complications  of  intense  inflammation  of  the  urethra,  while  swelled  testicle 
is  a  sequence  so  common  as  to  be  often  considered  a  complication  rather 
to  be  expected  than  not  in  severe  cases.  Inflammatory  complications  of 
the  fundus  of  the  bladder,  and  of  the  kidneys,  are  possible,  but  rare  in 
connection  with  gonorrhoea. 

When  the  urethral  inflammation  runs  high,  haemorrhage  from  the  ure- 
thra may  occur,  either  spontaneously  during  erection  or  as  a  result  of 
straightening  the  curved  penis  during  erection.  When  the  penis  is  so 
straightened  the  inflamed  spot  of  corpus  spongiosum  may  be  ruptured 
through  the  mucous  membrane  of  the  urethra,  and  violent  haemorrhage 
may  follow,  to  say  nothing  of  the  traumatic  stricture  which  is  sure  to  ap- 
pear subsequently  at  the  point  of  rupture. 

In  those  rare  cases  where  upward  chordee  appears  on  account  of  in- 
flammation of  the  corpus  cavernosum,  violent  straightening  may  cause  ef- 
fusion of  blood  within  the  sheaths  of  the  corpora  cavernosa,  but  rarely 
produces  free  bleeding  from  the  urethral  surface. 

After  the  urethral  flow  has  continued  at  its  height  for  a  period  vary- 
ing from  one  to  a  number  of  weeks,  all  the  inflammatory  symptoms  grad- 
ually subside,  chordee  becomes  less  frequent  and  less  intense  at  night, 
the  discharge  lessens,  and  finally  ceases  entirely.  It  may  relapse,  leading 
to  a  new  discharge  lasting  for  several  weeks,  or  prolong  itself  indefinitely 
in  the  shape  of  a  gleet,  which  is  more  or  less  puriform  in  different  cases, 
and  subject  to  exacerbation  and  improvement,  from  time  to  time,  from 
varied  trivial  causes. 


GONORRHOEA    IN    THE    MALE.  257 


GLEET. 

Gleet  is  chronic  urethritis.  A  severe  and  protracted  gonorrhoea  may 
run  on  into  a  gleet  after  passing  through  the  acute  stage,  and  remain  as  a 
gleet  indefinitely.  The  discharge  from  the  urethral  orifice  in  gleet  is  a 
blue,  thick,  mucoid  material,  more  or  less  purulent  and  creamy  in  different 
cases.  Generally,  in  gleet,  the  lips  of  the  meatus  are  found  sticking  to- 
gether when  the  patient  wakes  in  the  morning,  a  small  amount  of  the 
discharge  having  scabbed  over  the  meatus.  Behind  the  scab  there  may 
be  a  drop  of  pus,  or  there  may  be  none. 

Some  cases  of  urethritis  are  so  mild  that  they  are  gleety  from  the 
start,  and  never  become  freely  purulent. 

Gleet  may  exist  as  a  symptom  of  stricture  of  the  urethra,  and  of  the 
most  varied,  prostatic,  inflammatory,  and  degenerative  troubles,  not  in  the 
least  degree  venereal  in  origin.  The  only  real  interest  which  attaches  to 
gleet  in  a  venereal  way  is  the  question  of  the  contagiousness  of  gleet. 

The  gleet  following  a  gonorrhoea  is  poisonous.  How  long  it  retains 
its  virulent  quality  is  not  known.  Gleet  from  stricture  and  prostatic  le- 
sions does  not  possess  contagious  qualities.  It  is  often  impossible  to  pro- 
nounce positively  upon  a  gleet,  and  to  say  whether  it  is  contagious  or  not; 
but  there  is  a  very  safe  rule  to  go  by,  namely:  when  a  gleet  is  frankly  and 
freely  purulent  it  is  apt  to  possess  contagious  properties  ;  gleet  which  is 
mucoid,  blue  in  color,  sticky  in  consistence,  is  incapable  of  lighting  up  in- 
ilammatory  trouble  in  another. 

17 


CHAPTER    II. 

TREATMENT  OF  URETHRAL  INFLAMMATION  IN  THE  MALE. 

The  Relation  of  the  Physician  to  his  Patient  during  the  Treatment  of  Urethritis. — The 
Abortive  Treatment  of  Gonorrhoea.— Hygienic  Treatment ;  Medical  Treatment  by 
Alkaline  Diuretics,  by  Sandal- Wood  Oil,  by  Copaiba  (Copaibal  Erythema),  by  Cu- 
bebs.  by  Turpentine,  by  Iron,  by  Tincture  of  Cantharides. — The  Internal  Treat- 
ment of  Gleet. — The  Use  of  Injections  in  Urethritis. — How  to  Inject  the  Urethra. 
— Dressings  for  the  Penis  during  Urethritis.  —  Treatment  of  Chordee. — Treatment 
of  Painful  Urination. — Treatment  of  Retention  of  Urine  in  Gonorrhoea. — Treat- 
ment of  Venereal  Warts. — Treatment  of  Inflammatory  Phimosis. — Paraphimosis 
and  its  Treatment. 

THE  treatment  of  Urethritis  is  accompanied  by  moral  difficulties  not 
experienced  to  the  same  extent  in  connection  with  any  other  malady. 
When  a  man  gets  urethritis  he  rarely  feels  willing  to  acknowledge  that  it 
is  largely,  perhaps  wholly,  his  own  fault;  and  it  is  not  customary  to  see 
him  stand  up  and  take  his  punishment  like  a  man.  He  generally  accuses 
his  partner  of  all  the  blame  for  his  misfortune,  although  she,  indeed,  may 
have  no  contagious  disease;  he  feels  ashamed  of  himself,  tries  to  sneak 
out  of  his  troubles,  and  demands  of  his  physician  anything  and  everything, 
asserting  that  he  positively  must  be  cured  in  a  few  days.  He  will  nearly 
always  demand,  with  impatience,  how  long  it  will  be  before  he  will  be 
well,  and  he  calls  for  violent  measures  in  order  that  the  course  of  the  dis- 
ease may  be  cut  short.  If  he  is  not  satisfied  on  these  points,  and  prom- 
ised a  speedy  cure,  he  refers  to  some  friend,  or  perhaps  to  a  number  of 
friends,  who  laugh  at  gonorrhoea,  and  tell  him  that  they  constantly  get 
it  and  cure  it  for  themselves  in  a  few  days  with  some  favorite  prescription; 
and  it  is  by  the  standard  of  this  misinformation  from  friends  that  the  result 
of  the  physician's  efforts  is  often  judged. 

In  syphilis  the  patient  is  far  more  frightened  than  when  he  has  gonor- 
rhoea, but  he  never  disturbs  the  physician  by  asking  for  a  cure  within  a 
few  days.  The  popular  idea  about  syphilis  is  that  it  lasts  forever,  and 
the  patient  with  this  disease  asks  his  physician  not  to  cure  him  promptly, 
but  whether  he  ever  can  get  the  poison  thoroughly  out  of  his  "  system," 
as  he  puts  it. 

If,  therefore,  the  surgeon  allows  himself  to  be  browbeaten*  by  the  ig- 
norance of  his  patient,  he  has  to  commence  the  treatment  of  urethritis — a 
very  obstinate  disease — under  most  disadvantageous  auspices;  and  the 
patient  is  apt  in  the  end  to  be  dissatisfied  with  the  result,  no  matter  how 
creditable  that  result  may  really  be.  To  be  just  to  himself,  the  surgeon 
must  start  as  master  of  the  field,  if  he  hopes  for  any  comfort;  and  the  only 
way  to  do  this  with  a  foolish  young  man  suffering  from  his  first  attack,  or 
with  an  anxious  husband  who  expects  his  wife  to  return  home  in  ten 
days,  is  to  have  a  perfect  understanding  at  the  very  commencement  of 
treatment. 

The  patient  should  be  informed  that  gonorrhoea,  badly  managed,  is  as 


TREATMENT  OF  URETHRAL  INFLAMMATION  IN  THE  MALE.   259 

serious  a  matter,  in  many  cases,  as  syphilis;  that  gonorrhoea  probably  kills 
more  patients  than  syphilis  does,  through  its  ultimate  effect,  by  means  of 
stricture  of  the  urethra,  upon  the  bladder  and  the  kidneys.  If  the  patient's 
associates  find  gonorrhoea  to  be  so  light  a  matter,  it  is  well  to  refer  him 
back  to  them  for  treatment.  The  surgeon  should  absolutely  refuse  in  any 
case  to  give  a  promise  of  cure  in  any  given  time.  He  cannot  give  such 
an  assurance  honestly,  and  if  he  happens  to  hit  right  with  his  guess  in  the  ' 
case  of  one  patient,  that  patient  will  injure  his  reputation  greatly;  for  he 
will  boast  among  his  companions  of  a  prompt  cure  within  a  certain  prom- 
ised number  of  days,  and  his  friends  will  come  with  their  gonorrhoeas  and 
demand  a  like  promise  and  a  like  speedy  cure,  and  failing  to  get  it,  will 
denounce  the  physician  as  incompetent.  No  man  can  positively  assert  at 
the  start  whether  a  given  urethral  inflammation  just  commencing  at  the 
pouting  orifice  of  a  healthy  urethra  is  to  be  a  severe  case  or  not,  or  whether 
it  will  yield  a  prompt  response  to  remedies. 

If  a  man  has  already  had  several  attacks  of  gonorrhoea,  and  his  present 
attack  comes  on  without  any  oedematous  swelling  of  the  meatus  urinarius, 
the  chances  are  that  the  attack  will  be  a  mild  one.  If  the  case  is  one  of 
first  attack,  and  there  has  been  not  more  than  forty-eight  hours'  incuba- 
tion, the  chances  also  are  that  the  inflammation  will  not  be  violent.  If 
there  has  been  no  sexual  intercourse  at  all  to  occasion  the  new  outbreak, 
then,  although  the  course  of  the  malady  may  be  slow  and  its  duration 
protracted,  the  symptoms  are  not  apt  to  run  high. 

In  any  case,  so  far  as  making  a  prognosis  is  concerned,  it  is  proper  to 
say  to  the  patient  that  he  has  a  disorder  which  is  perfectly  curable  by 
gentle  treatment,  but  which  often  fails  to  get  well  if  harsh  measures  are 
used;  that  the  symptoms  require  intelligent  management,  according  to 
their  intensity;  that  it  is  safer  and  surer  in  the  end  to  make  haste  slowly, 
and  that  all  will  be  done  by  treatment  that  can  be  effected  by  drugs. 

Under  such  an  understanding,  the  surgeon's  hands  are  free,  and  the 
patient's  mind  at  rest,  because  he  (the  patient),  under  the  circumstances, 
will  either  seek  treatment  elsewhere,  or  he  will  yield  himself  up  to  his 
physician,  and  follow  his  instructions  with  willing  confidence.  Then,  if 
the  case  turns  out  to  be  a  mild  one,  and  gets  well  in  a  fortnight,  the  pa- 
tient is  delighted  and  appreciative.  If  it  drags  itself  along  for  two  or 
three  months,  he  is  regretful,  but  satisfied. 

The  abortive  treatment  of  gonorrhrea  should  not  be  attempted. 
It  is  accompanied  by  considerable  danger,  and  is  absolutely  uncertain. 
Those  cases  which  get  well  under  its  use  are  cases  of  urethritis  which 
doubtless  would  have  recovered  promptly  under  mild  treatment.  When 
it  does  not  cure,  it  greatly  increases  the  grade  of  intensity  of  the  inflam- 
mation, and  leads  with  much  certainty  to  stricture  ultimately,  and  imme- 
diately in  many  cases  to  complications  on  the  side  of  the  bladder  and  tes- 
ticle, not  devoid  of  danger  to  important  functions.  As  a  general  rule,  it 
will  be  found  that  those  who  have  most  faith  in  the  value  of  the  abortive 
treatment  are  those  who  have  not  tried  it  at  all,  or  medical  men  and 
young  practitioners  who  have  not  had  much  experience  with  the  disease. 
After  a  few  disastrous  failures,  the  practice  is  generally  abandoned.  The 
few  authorities  in  high  position  who  advocate  the  abortive  treatment  are 
becoming  yearly  more  oracular  in  their  utterances,  more  reserved  in  prom- 
ising any  certain  effect  from  the  use  of  harsh  injections  very  early  in  the 
course  of  a  gonorrhoea.  I  do  not  assert  that  abortive  treatment  does  not 
sometimes  seem  to  cut  short  an  attack  of  urethral  inflammation,  but  I  cer- 
tainly maintain  that  no  man  can  assert  that  it  will  always  do  so,  no  mat- 


260  THE    VENEREAL    DISEASES. 

ter  how  it  is  used;  and  I  believe  that  the  damage  it  does  in  the  cases  in 
•which  it  fails  far  outbalances  the  alleged  good  it  accomplishes  in  cases 
of  apparent  success.  I  doubt  greatly  whether  a  true  virulent  gonorrhoea 
can  be  aborted  by  the  use  of  strong  or  astringent  injections  at  the  start. 

The  treatment  of  urethritis  which  aims  at  an  intelligent  management 
of  the  symptoms  according  to  their  intensity,  once  adopted,  is  not  likely 
to  be  given  up  for  any  other  plan,  because  the  results  are  in  the  main  so 
satisfactory.  This  treatment  is  hygienic  and  medicinal. 

Hygienic  treatment  of  urethritis. — Absolute  regularity  of  life 
should  be  enjoined  in  all  cases  from  the  start;  anything  like  irregularity 
is  detrimental.  The  patient  should  rest  as  much  as  possible,  lying  clown 
rather  than  sitting  or  walking.  He  should  indeed  avoid  exercise  at  first, 
and  keep  as  far  as  possible  in  a  uniform  temperature.  Regularity  should 
be  practised  in  sleeping  and  in  eating,  and  particular  attention  should 
be  bestowed  upon  the  function  of  the  intestine. 

The  amount  of  food  taken  at  the  beginning  of  an  attack  should  be 
moderate,  its  quality  bland  and  unstimulating,  its  nature  light  and  varied. 
If  the  patient  be  debilitated,  on  the  other  hand,  plenty  of  meat  should  be 
allowed,  the  full  ordinary  amount  of  food  should  be  taken,  and  in  some 
cases  even  a  little  red  wine  from  the  very  beginning.  Milk  is  an  excellent 
article  of  diet  in  all  cases.  Where  it  cannot  be  promptly  digested,  the 
work  of  the  stomach  may  be  made  easier  by  adding  salt  to  the  milk;  and 
a  laxative,  such  as  a  dinner-pill,  may  be  given  at  night,  or  a  little  com- 
pound liquorice  powder,  or,  if  the  patient  prefers,  some  bitter  sulphate  of 
soda-water  in  the  morning. 

Among  the  articles  of  food  to  be  avoided  in  all  acute  cases  (excepting 
those  coming  on  in  decidedly  debilitated  subjects,  when  intelligent  excep- 
tions must  be  made),  are  pastry,  gravies,  fried  fats,  and  greasy  articles  of 
food,  all  rich  made-dishes  and  indigestible  substances,  all  condiments  of 
every  description,  excepting  in  the  mildest  form.  Salt,  however,  is  not 
objectionable;  pickles  and  acids  usually  are.  Asparagus  is  harmful  to 
some  patients.  « 

Among  the  drinks  to  be  avoided  are  strong  coffee  and  tea;  chocolate 
in  any  form,  since  this  beverage  stimulates  the  sexual  appetite;  all  wines 
and  liquors  of  any  description,  particularly  the  fermented  wines  and  malt 
liquors. 

Soda-water,  root- beer,  and  Vichy  water,  may  be  used  as  beverages 
with  decided  advantage,  and  the  more  water  that  can  be  taken  between 
meals  the  better,  particularly  rain-water,  which  is  very  bland  to  the  stom- 
ach and  a  mild  diuretic.  It  is  always  well  for  patients  to  take  a  full 
glass  of  water  upon  retiring,  so  that  the  morning  urine  may  be  less  dense 
than  would  otherwise  be  the  case. 

Smoking  is  not  objectionable. 

The  mind  should  be  kept  absolutely  free  from  impure  thoughts  during 
the  whole  of  the  attack,  and  no  sexual  excitement  permitted  for  a  moment. 
The  penis  should  be  handled  as  little  as  possible. 

This  latter  precaution  must  be  strictly  enforced  for  two  reasons.  In 
the  first  place,  the  constant  pulling  at  the  urethra,  in  order  to  see  how 
much  pus  it  contains  and  what  its  quality  may  be,  is  very  irritating  to  the 
inflamed  mucous  membrane  of  the  canal.  In  the  second  place,  fingering 
the  urethra  exposes  the  eyes  of  the  patient  to  inadvertent  inoculation. 
The  caution  of  extreme  cleanliness  and  avoidance  of  the  contact  of  any 
pus  from  the  urethra  with  the  conjunctiva  should  be  very  forcibly  given 
to  each  patient,  and  frequently  repeated  and  insisted  upon. 


TEEATMENT  OP  URETHKAL  INFLAMMATION  IN  THE  MALE.       261 

As  a  final  hygienic  precaution  it  is  well  for  the  patient  to  carry  his 
testicles  in  a  suspensory  bandage,  since  the  tendency  to  epididymitis  is 
in  this  way  decidedly  lessened. 

All  the  hygienic  precautions  alluded  to  should  be  held  in  force  during 
the  whole  course  of  an  urethral  discharge,  and  for  a  considerable  period 
after  its  apparent  cessation  (a  week  to  ten  days),  through  fear  of  a  relapse. 

The  medical  treatment  of  urethral  inflammation  is  regulated 
by  the  stage  of  the  disease  and  the  intensity  of  the  symptoms.  The  first 
thing  to  be  done  in  all  cases  is  to  see  that  the  urine  be  made  abundant 
and  alkaline,  so  that  it  may  be  bland  and  unirritating  in  its  passage  over 
the  inflamed  surface  of  the  urethral  mucous  membrane.  To  accomplish 
this  dilution  of  the  urine  it  may  be  enough  to  take  an  extra  tumbler  of 
water  several  times  a  day  between  meals,  or  of  Bathesda  water  or  of  Vichy 
water.  Should  the  dilution  of  the  urine  not  materially  reduce  its  acidity, 
some  alkaline  drug  may  be  given  well  diluted  with  water,  and  adminis- 
tered during  the  third  hour  after  each  meal.  If  an  alkali  is  given  on  an 
empty  stomach  before  eating,  the  flow  of  acid  during  the  next  meal  is 
pretty  certain  to  be  greater,  and  the  result  upon  the  blood  of  the  alkali 
as  a  medicine  to  be  proportionately  diminished.  If  an  alkali  is  given 
during  a  meal,  its  effect  upon  the  blood  is  largely  counteracted  by  the 
acidity  of  the  digestive  juices.  Given  during  the  third  hour  after  a  meal, 
the  greatest  amount  of  therapeutical  effect  is  obtained  from  the  least 
amount  of  the  drug;  consequently,  when  practicable,  this  hour  should  be 
chosen  for  the  administration  of  the  remedy. 

The  best  alkaline  drug,  in  cases  of  irritation  of  the  bladder  or  urethra, 
is  the  citrate  of  potash.  This  salt,  however,  is  unstable.  In  solution, 
after  being  kept  for  a  time,  it  becomes  changed  to  the  carbonate  of  pot- 
ash; and  even  in  the  dry  state,  if  exposed  to  the  air,  it  undergoes  a  simi- 
lar alteration  in  part.  The  carbonate  of  potash,  although  a  fair  alkali,  is 
not  so  good  a  diuretic  as  the  citrate,  and  does  not,  as  a  rule,  agree  so  well 
with  the  stomach.  Finally,  it  may  be  well  to  state  that  the  apothecary 
generally  buys  his  citrate  of  potash  in  a  bottle  holding  a  pound  of  the 
powder;  from  this  bottle  he  dispenses,  and  the  pound  may  last  him  many 
months.  In  such  a  case  all  those  served  after  the  first  few  customers  must 
necessarily  get  an  inferior  article. 

Therefore,  when  citrate  of  potash  is  prescribed  for  a  patient,  it  is  well 
to  order  him,  if  possible,  to  procure  his  supply  from  a  freshly-opened  bot- 
tle, and  to  whatever  quantity  may  be  necessary,  dry  in  the  powder,  in  wide- 
mouthed  ounce-bottles  tightly  corked.  Along  with  his  bottles,  in  a  small 
drachm-bottle,  he  should  receive  a  single  dose,  be  it  five,  ten,  twenty,  or 
thirty  grains,  so  that  from  his  wide-mouthed  bottle  he  may  take  out  a  por- 
tion equal  to  the  sample  for  each  dose,  and  may  make  a  fresh  solution  in 
a  claret-glass  of  water  each  time  that  he  takes  the  medicine.  In  this  way 
'he  will  always  have  a  fresh  article,  since  by  taking  three  doses  a  day  he 
will  use  up  an  ounce  before  any  of  it  has  had  time  to  spoil,  if  he  keeps 
the  bottle  corked. 

Occasionally  the  citrate  of  potash  disagrees  with  the  stomach,  even 
when  taken  with  all  possible  precautions.  Under  such  circumstances  it 
produces  a  sense  of  discomfort  in  the  region  of  the  stomach,  perhaps  nau- 
sea, possibly  diarrhoea,  and  sometimes  a  pain  in  the  head  across  the  fore- 
head. In  these  cases  the  remedy  must  be  discontinued,  and  some  other 
alkali  tried,  or  Vichy  water  substituted. 

The  dose  of  the  citrate  of  potash  vaires  from  five  to  thirty  grains. 
Just  enough  should  be  given  to  keep  the  urine  constantly  neutral  or 


262  THE    VENEREAL    DISEASES. 

slightly  alkaline.  If  the  citrate  of  potash  cannot  be  obtained  or  disagrees, 
the  bicarbonate  of  soda  or  of  potash  may  be  used,  or  liquor  potassae  in 
sufficient  quantities  to  produce  the  desired  effect. 

The  means  already  detailed  are  of  service  in  all  cases;  but,  in  selecting 
further  remedies,  some  discrimination  is  desirable. 

If  the  case  is  one  in  which  there  is  reason  to  suspect  that  the  discharge 
comes  from  a  patch  of  damaged  urethra,  strictured  or  not,  which  has  been 
excited  to  suppuration — where,  for  instance,  a  drop  of  pus  appears  at  the 
beginning  of  the  attack  in  a  meatus  which  is  not  oedematous  or  swollen, 
in  such  a  case  there  is  generally  no  occasion  for  any  further  internal  medi- 
cation than  the  alkaline  diuretics  already  alluded  to.  A  very  mild  injec- 
tion may  be  used  at  once,  increased  in  strength  every  few  days;  and  very 
often  in  a  short  time  the  supposed  gonorrhoea  subsides,  and  the  patient 
rejoices  in  an  escape  from  a  prolonged  sickness  whfch  he  had  perhaps 
looked  upon  as  inevitable.  The  qualities  of  the  different  substances  used 
for  injection  into  the  urethra  will  receive  consideration  presently. 

In  case  the  orifice  of  the  urethra  is  pouting,  indicating  the  probability 
of  a  commencing  acute  attack,  the  best  substance  to  use  in  most  cases  in 
connection  with  the  alkali  is  the  oil  of  sandal-wood.  The  pure  oil  is  very 
expensive,  and  what  is  sold  is  apt  to  be  much  adulterated,  especially  if 
bought  at  cheap  drug-stores.  Consequently,  it  is  not  advisable  to  order 
this  remedy  to  poor  people.  The  value  of  the  drug  is  not  therapeutically 
great  enough  to  justify  a  poor  man  in  preferring  it  to  copaiba.  The  pa- 
tient in  good  circumstances  may  take  it  in  the  form  of  capsules,  or  dropped 
upon  a  lump  of  sugar  in  increasing  doses,  commencing  at  ten  drops  at  a 
dose,  and  working  up  to  perhaps  as  much  as  thirty  drops.  One  capsule 
is  enough  to  commence  with,  and  three  generally  as  many  as  the  stomach 
can  bear. 

Sometimes  it  may  be  desirable  to  give  the  oil  and  the  alkali  combined 
in  a  single  prescription,  such  as  the  following,  which  is  not  unpalatable: 

3  •     Ol.  santali §  ss. — i. 

Liq.  potassas 3  ij. — iv. 

Syr.  acacife 3  i. 

Aquae  foeniculi q.  s.  ad  §  iij. 

M. 
S.  Teaspoonful,  well  diluted,  in  the  third  hour  after  eating. 

Sandal-oil  agrees  with  most  stomachs  much  better  than  copaiba.  It 
produces  no  trouble  upon  the  skin,  and  is  not  apt  to  excite  diarrhoea. 
When  it  disagrees,  it  generally  does  so  by  causing  intense  pain  in  the 
back,  over  the  region  of  the  kidneys.  In  pushing  the  drug  to  obtain  its 
full  effect,  it  is  well  to  continue  increasing  the  dose  until  some  uneasi- 
ness is  complained  of  in  this  region,  and  then  to  interrupt  it  for  a  day  or 
more,  waiting  for  the  pain  to  subside,  as  it  does  quite  promptly.  After 
this  the  drug  may  be  resumed  at  an  appropriate  dose. 

The  effect  of  sandal-oil  in  full  doses  is  usually  soothing  to  the  patient's 
sensations.  In  cases  of  ordinary  urethritis  it  often  promptly  modifies  the 
intensity  of  the  discharge.  In  true  gonorrhoea  it  is  less  effective,  and 
sometimes  seems  to  exert  no  influence  whatsoever. 

If  the  patient  be  poor,  sandal-oil  should  not  be  thought  of,  but  the 
balsam  of  copaiba  should  be  used  at  once.  If  he  be  well-to-do,  and  the 
sandal-oil  has  helped  him  but  little  or  not  at  all,  then  also  recourse  may 
be  had  to  copaiba,  which,  although  difficult  to  take  and  hard  to  digest,  is 


TREATMENT  OF  URETHRAL  INFLAMMATION  IN  THE  MALE.   263 

more  efficacious  in  many  cases.  The  balsam  is  inexpensive  and  therefore 
generally  quite  pure,  no  matter  where  obtained.  It  is  put  up  in  capsules 
by  a  number  of  manufacturers,  and  these  capsules  may  be  taken  with  the 
alkaline  diuretic,  commencing  at  a  dose  of  one,  and  increasing  until  three 
or  even  four  are  taken  at  a  time.  The  balsam  may  be  given  in  combina- 
tion with  the  alkali,  in  a  prescription  similar  to  the  one  already  advised 
for  sandal-wood  oil,  or  in  one  of  the  following  mixtures: 

R.     Bals.  copaibas f  ss. — i. 

Liq.  potassas 3  ij- — iv. 

Syr.  tolu |  iss. 

Extr.  glycyrrhizse 3  ij. 

Aquae  menth.  pip q.  s.  ad  f  iij. 

M.    Shake. 
S.  One  to  two  teaspoonfuls  at  a  dose. 

R.     Bals.  copaibas 3  iv. 

Syr.  tolu, 
Syr.  acacias, 

Aquae  menth.  pip aa  3  viss. 

M.    Shake. 
S.  Teaspoonful. 

The  balsam  may  be  administered  in  an  endless  variety  of  combinations, 
mixed  with  sandal-oil,  with  cubebs,  solidified  into  pills  with  magnesia, 
and  in  countless  mixtures.  In  general,  the  method  by  capsules  is  most 
convenient  and  palatable,  since  the  drug  is  only  tasted  during  the  regur- 
gitations  in  the  throat,  which  are  so  constant  and  offensive  in  some  peo- 
ple when  they  take  copaiba.  The  odor  of  the  balsam  also  remains  on  the 
breath,  and  is  quite  strong  in  the  urine  of  the  patient  in  all  cases. 

Copaiba  disagrees  with  many  patients.  It  causes  acute  indigestion 
in  some,  and  more  moderate  dyspepsia  in  others.  Sometimes  it  will 
not  stay  down  at  all,  but  is  rejected  by  the  stomach.  Occasionally  it 
produces  headache  and  great  depression  of  spirits.  Sometimes  it  causes 
diarrhoea.  The  urine,  when  full  of  copaiba,  may  coagulate  under  heat  in  a 
manner  suggestive  of  the  presence  of  albumen. 

Copaiba!  erythema. — One  of  the  specific  effects  of  copaiba  is  to 
produce  an  acute  eruptive  disorder,  known  as  copaibal  roseola  or  ery- 
thema. Its  advent  is  frequently  announced  by  a  chill,  with  headache  and 
nausea,  sometimes  by  diarrhoea  and  considerable  fever.  The  eruption  is 
general,  and  consists  of  red  raised  blotches  which  itch  intensely. 

When  the  eruption  appears,  the  urethral  discharge  becomes  greatly 
modified,  or  ceases  entirely,  but  it  generally  returns  as  the  eruption  fades. 

The  treatment  of  copaibal  erythema  is  to  give  plenty  of  fluids  by  the 
mouth,  and  bland  diuretics,  to  assist  the  kidneys  in  eliminating  the 
offending  substance  from  the  blood.  Warm  baths  are  comforting,  espe- 
cially if  they  contain  a  little  baking-soda — about  one  ounce  to  thirty 
gallons — or  some  of  the  infusion  of  bran,  as  in  the  ordinary  bran-bath. 
Dusting  the  skin  with  starch-powder  is  cooling,  and  a  few  days  generally 
suffices  to  so  moderate  the  eruption  that  the  itching  is  no  longer  distress- 
ing. On  the  first  appearance  of  this  eruption  the  copaiba  must  be 
stopped;  but  it  may  be  resumed  again,  if  it  be  desired,  in  smaller  doses, 
after  the  eruption  is  well  on  the  decline. 

Copaiba  is  undoubtedly  a  very  useful  drug  in  the  treatment  of  gonor- 


264  T1IE   VEXEKEAL   DISEASES. 

rhoea.  The  very  fact  that  it  still  continues  to  be  used,  in  spite  of  its 
nauseousness,  is  sufficient  proof  of  this.  Yet  it  is  not  well  to  expect  too 
much  of  it.  It  sometimes  acts  admirably  in  cases  of  urethritis,  and  is 
evidently  comforting  in  many  cases  of  gonorrhoea,  but  it  does  not,  and  it 
should  not  be  expected  to,  jugulate  the  disease.  By  its  effects  it  must  be 
judged.  It  is  valuable  in  the  increasing  and  in  the  stationary  period  of 
the  malady.  If  it  gives  a  little  comfort  and  checks  the  discharge  some- 
what, it  should  be  continued,  provided  the  stomach  is  not  too  much  dis- 
turbed by-  its  use.  As  soon  as  the  stationary  period  draws  to  its  close, 
and  the  discharge  is  fairly  checked  and  positively  on  the  decline,  copaiba 
generally  ceases  to  be  very  useful,  and  has  to  give  place  to  cubebs. 

Gurjun  balsam,  in  drachm  doses,  twice  a  day,  has  been  of  late  re- 
commended in  place  of  copaiba.  It  is  said  to  be  more  agreeable  to  the 
stomach.  It  may  be  prescribed  in  mixtures  similar  to  those  in  which 
copaiba  forms  the  chief  ingredient. 

When  the  discharge  commences  to  decline,  cubebs,  turpentine,  iron 
and  cantharides  are  the  best  remedies,  of  relative  efficacy  in  the  order 
given. 

Cubebs  may  be  administered  as  a  powder,  or  in  drachm-doses  of  the 
fluid  extract.  The  oleo-resin  is  the  most  useful  preparation,  in  my  opin- 
ion, and  that  made  by  Merck,  of  Darmstadt,  the  best  of  its  kind.  Plan- 
ten  has  put  up  this  oleo-resin  in  capsular  form.  The  dose  is  from  ten  to 
thirty  minims,  and  it  may  be  administered  in  various  ways.  Small  quan- 
tities are  easily  taken  upon  a  lump  of  sugar,  larger  doses  best  in  capsules. 
One  capsule  at  a  dose  is  enough  to  begin  with,  to  be  gradually  increased. 
Patients  generally  halt  at  three  capsules  at  a  dose,  but  sometimes  they 
take  four. 

The  effect  of  cubebs  in  moderate  doses  is  rather  to  stimulate  diges- 
tion and  act  as  a  tonic.  The  breath  smells  of  it,  and  the  urine  is  full  of 
its  odor.  Large  doses  are  distinctly  irritating  to  the  stomachs  of  most 
patients,  and  cause  diarrhoea,  with  griping  pain.  If  the  neck  of  the  bladder 
happens  to  be  at  all  congested,  or  if  the  organ  tends  to  be  irritable,  cubebs 
is  generally  harmful,  since  it  aggravates  such  conditions,  and,  if  pushed, 
may  go  so  far  as  to  bring  on  inflammation  of  the  neck  of  the  bladder. 

Turpentine  is  sometimes  useful  in  the  declining  stage  of  gonorrhoea, 
and  may  be  given  in  those  cases  in  which  cubebs  does  not  agree.  The  oil 
of  turpentine  may  be  taken  upon  a  lump  of  sugar,  in  five-  to  twenty-drop 
doses,  three  or  four  times  a  day.  If  preferred,  it  may  be  given  very  con- 
veniently in  the  form  of  the  pearls  of  turpentine,  as  they  are  called — 
prepared  by  Clertan.  The  dose  of  these  is  from  one  to  three. 

Sometimes  turpentine  acts  as  an  irritant,  just  as  cubebs  does,  and  in- 
duces frequent  urination.  In  such  case,  the  remedy  must  be  changed  or 
the  dose  lessened. 

Iron,  in  the  form  of  the  tincture  of  the  sesquichloride,  is  a  time-hon- 
ored remedy  in  the  treatment  of  the  subsiding  stage  of  gonorrhoea,  espe- 
cially when  it  tends  to  become  gleety.  Besides  the  tonic  properties  of 
iron,  this  tincture  is  believed  to  exercise  an  especial  influence  over  the 
genito-urinary  system.  The  dose  is  from  ten  to  thirty  drops  in  water, 
three  times  a  day,  taken  through  a  glass  tube  upon  a  full  stomach.  It  is 
certainly  very  beneficial  at  times. 

If  iron  makes  the  head  ache  or  produces  positive  constipation,  it  is  not 
likely  to  do  much  good  to  the  urethral  discharge.  The  constipating  in- 
fluence may  be  counteracted,  however,  by  combining  with  each  dose  from 
ten  to  thirty  minims  of  the  fluid  extract  of  buckthorn. 


TREATMENT  OF  URETHRAL   INFLAMMATION  IN  THE  MALE.       265 

Tincture  ofcantharid.es  enjoyed  considerable  reputation  at  one  time 
as  a  stimulus  in  the  last  stage  of  a  declining  gonorrhoea.  It  is  but  little 
used  at  the  present  day,  but  yet  there  is  virtue  in  it,  and  in  obstinate  cases 
it  may  be  tried,  taken  pretty  well  diluted  with  water  upon  a  full  stomach, 
in  from  five-  to  twenty-drop  doses. 

When  used  in  large  doses  this  remedy  also  has  a  decided  tendency 
to  produce  irritation  at  the  neck  of  the  bladder.  Indeed,  if  taken  in  over- 
doses, it  causes  inflammation  of  the  vesical  neck  quite  certainly  "with 
strangury,  bloody  urine,  etc. 

The  internal  treatment  of  gleet  is  the  same  as  that  suitable  for  the 
declining  stage  of  gonorrhoea,  that  is,  if  the  gleet  follows  close  upon  a  gon- 
orrhoea and  is  its  prolonged  winding  up.  Generally,  however,  when  a  gleet 
prolongs  itself  after  a  gonorrhoea,  it  is  either  because  the  patient  is  too 
much  medicated  and  cannot  employ  his  stomach  satisfactorily  for  its 
proper  function,  the  conversion  of  food  into  a  pulp  ready  for  intestinal 
digestion,  or  it  is  because  there  is  some  local  lesion  in  the  urethra  (stric- 
ture, prostatitis),  or  constitutional  defect  (debility,  tubercle,  gout). 

Under  these  circumstances  iron  and  turpentine  are  about  the  only  in- 
ternal remedies  likely  to  do  good.  Wine  should  be  given,  a  generous  diet 
ordered,  change  of  air  and  relaxation  from  work.  Cod-liver  oil  sometimes 
has  an  excellent  effect  in  these  cases. 

Local  treatment  is  of  the  utmost  value  in  these  cases.  The  intelligent 
use  of  injections  takes  first  rank  where  there  is  no  stricture,  and  if  the  lat- 
ter exist,  even  of  very  large  calibre,  its  treatment  should  be  undertaken 
at  once  as  a  proper  treatment  for  the  gleet. 


THE    USE    OF    INJECTIONS    IN    URETHBITIS. 

Injections  of  the  urethra  are  capable  of  rendering  invaluable  service  in 
urethritis,  but  when  inappropriately  used  they  may  occasion  much  mis- 
chief. The  only  safe  rule  for  guidance  in  grading  the  strength  of  an  ure- 
thral  injection  is  to  determine  to  get  all  the  good  that  seems  possible  out 
of  a  given  weak  injection  before  resorting  to  a  stronger  one,  and  not  to 
start  with  the  idea  that  the  urethra  must  be  made  to  stand  a  strong  injec- 
tion in  order  that  it  may  be  forced  into  a  rapid  recovery  from  its  lesions. 
No  injection  should  be  used  in  the  urethra  which  produces  any  uncom- 
fortable sensation  lasting  more  than  four  or  five  minutes  at  the  most.  It 
is  desirable  in  most  cases  to  produce  a  warm,  pricking  sensation,  which 
may  become  uncomfortable  for  a  moment  or  two;  but  a  positive  pain 
generally  means  that  some  chemical  violence  has  been  done  to  the  surface 
of  the  urethra,  and  such  violence  may  be  the  starting-point  of  stricture. 

It  must  also  be  remembered,  in  regard  to  a  given  injection,  that  if  it 
does  not  do  the  good  required  of  it,  a  different  strength  of  the  same  in- 
gredient in  solution  may  have  the  desired  effect.  There  is  little,  if  any- 
thing, specific  about  injections.  The  reputation  which  hangs  about  cer- 
tain proprietary  injections  is  simply  the  glamour  of  mystery.  When  the 
composition  of  such  an  injection  becomes  known,  it  loses  its  great  renown 
and  takes  its  place  among  good  injections,  if  it  happens  to  be  good,  and 
there  are  a  great  many  very  good  injections.  A  practitioner  will  learn 
all  about  a  given  substance  if  he  uses  it  frequently,  and  it  is  advisable  for 
him  to  stick  to  one  or  two  substances  and  use  them  intelligently,  rather 
than  to  employ  a  great  variety  of  injections  in  the  hope  that,  by  skipping 
from  one  to  another,  he  may  hit  upon  some*peculiar  quality  which  his 


266  THE    VENEREAL    DISEASES. 

patient  really  needs,  but  which  he  has  not  the  wit  to  reason  out  before- 
hand. 

It  is  well  also  to  remember  that,  when  a  discharge  ceases  under  a 
given  injection,  it  may  return  promptly  if  the  injection  be  abruptly  discon- 
tinued. A  discharge,  indeed,  cannot  ever  certainly  be  pronounced  to  have 
ultimately  ceased  until  it  has  remained  well  for  a  week  ;  and  during  this 
week  of  expectation  the  same  injection  should  be  continued  which  has  been 
successfully  employed,  with  this  difference,  theft  it  should  be  diminished 
in  strength  from  day  to  day,  and  used  at  longer  intervals  than  during  the 
cure. 

A  final  precaution  concerning  injections  is  this  :  occasionally  an  in- 
jec^ion  produces  and  keeps  up  a  discharge  on  account  of  being  inappro- 
priately strong.  This  is  most  apt  to  be  the  case  with  young  men  who 
often  frighten  themselves  into  a  belief  that  they  have  a  gonorrhoea  when 
they  have  nothing  of  the  sort,  and  commence  a  fierce  onset  upon  the  urethra 
with  injections — a  treatment  which  promptly  excites  a  flow  of  pus  and 
confirms  their  fears.  On  the  other  hand,  at  the  close  of  a  gonorrhoea, 
when  an  injection  of  considerable  strength  has  been  employed  to  arrest 
the  purulent  discharge,  an  oozing  of  gleety  mucus  may  keep  on,  main- 
tained by  a  strong  injection  the  use  of  which  has  been  persisted  in. 

In  either  of  these  sets  of  cases  rapid  improvement  follows  a  cessation 
of  the  injection. 

The  method  by  which  the  urethra  may  be  most  conveniently  inject- 
ed requires  a  short  description.  Syringes  with  long  nozzles  are  little 
used  of  late  years,  and  several  varieties  of  short-nozzled  or  conical-ended 
instruments  are  in  the  market,  made  of  glass,  hard  rubber,  and  other  sub- 
stances. Any  of  these  will  do,  but  the  hard  rubber  urethral  syringe, 
known  by  the  trade  name  of  No.  1  A,  is  probably  the  best.  Long-nozzled 
syringes  have  the  disadvantage  of  scratching  the  urethra  with  their  tips, 
against  which  the  tender  mucous  membrane  is  forced  by  the  pressure  of 
the  fingers  clasping  the  urethra  upon  the  outside. 

Fig.  26  represents  the  No.  1  A  syringe.      Its  bulbous  tip  only  should 

be  introduced  into  the  urethra,  in 
order  to  make  an  injection  properly. 
It  is  a  mistake  to  crowd  the  conical 
tip  deeply  into  the  meatus.  This 

bruises  the  canal  perhaps  as  posi- 

pIO_  2g.  tively  as  does  the  long  nozzle  of  the 

old-fashioned  syringe,  the  only  dif- 
erence  being  that  the  injury  is  done  at  a  different  part  of  the  canal. 

In  using  an  injection,  the  latter  should  be  slightly  warmed,  or  at  least 
the  bottle  should  be  kept  in  a  warm  place,  so  that  its  temperature  may  be 
but  little  lower  than  that  of  the  body.  Warming  the  syringe  by  hold- 
ing it  a  moment  in  hot  water  will  sometimes  answer  all  purposes.  In 
this  way  the  urethra  receives  no  shock  from  cold,  and  does  not  contract 
painfully  upon  the  stimulating  fluid  which  is  thrown  into  it. 

The  syringe  is  filled  with  the  warmed  injection,  and  all  air  carefully 
expelled.  The  patient  now  urinates,  washing  the  pus  in  this  way  from 
the  inflamed  surfaces.  After  the  canal  is  fairly  free  from  urine,  the  noz- 
zle of  the  syringe  is  to  be  gently  introduced  just  beyond  the  bulbous  tip 
into  the  inferior  angle  of  the  meatus,  and  the  two  lips  of  the  orifice  are 
to  be  pressed  against  each  other  with  the  thumb  and  finger  of  the  disen- 
gaged hand.  The  lips  of  the  meatus  are  not  to  be  pressed  upon  or 
against  the  instrument,  but  against  each  other.  Now  the  canal  of  the 


TREATMENT  OF  URETHRAL  INFLAMMATION  IN  THE  MALE.       267 

urethra  must  be  very  gently  distended,  by  pushing  the  piston  slowly  home; 
the  syringe  may  be  at  once  removed,  the  injection  retained  about  thirty 
seconds,  and  then  allowed  to  escape. 

These  motions  constitute  the  whole  act  in  many  cases.  The  quantity 
of  fluid  held  by  the  syringe  is  not  enough  to  penetrate  into  the  canal 
farther  than  the  bulb,  and,  in  a  capacious  urethra,  not  as  far.  There  is 
little  chance  of  doing  harm,  therefore,  by  throwing  the  injection  too  deep- 
ly down  the  canal.  After  injections  have  been  used  for  a  time,  it  is  al- 
lowable to  manipulate  the  fluid  in  the  canal,  by  holding  the  meatus  shut 
with  the  finger  and  thumb  of  one  hand,  while  with  the  fingers  of  the 
other  hand,  the  fluid  is  pressed  forward  in  the  urethra  so  as  to  distend  it, 
and  backward,  so  as  to  make  it  penetrate  more  deeply.  In  so  pressing 
back  a  fluid,  the  finger  should  never  be  carried  beyond  the  penoscrotal 
angle,  or  the  fluid  may  be  driven  back  into  the  prostatic  sinus  and  light 
up  cystitis,  or  occasion  epididymitis.  A  light  injection  used  twice  a  day 
generally  does  more  good  than  a  strong  injection  used  only  once. 

The  time  to  use  injections  with  most  success  is,  when  a  discharge  is 
upon  the  decline,  after  the  height  of  the  inflammatory  stage  has  passed. 
In  cases  which  commence  deep  in  the  urethra,  where  the  meatus  does  not 
pout,  injections  may  be  used  from  the  very  beginning  of  the  attack  ;  in 
other  cases  it  is  better  to  wait  and  not  to  use  them  at  all  until  the  flow 
has  begun  to  yield  to  internal  medication. 

A  good  injection  to  begin  with  is  simple  dilute  lead- water.  This  is 
not  apt  to  do  any  harm,  and  its  effect  is  soothing. 

Sulphate  of  zinc  makes  a  standard  injection  of  great  value. 

5  •     Zinci  sulph gr.  ss. — iv. 

Aquae  rosae f  i. 

M. 

or  the  same  strength  of  zinc  may  be  used  in  combination  with  dilute  lead- 
water.  Such  a  mixture  contains  the  white  sediment  of  the  sulphate  of 
lead,  which  should  be  shaken  through  the  mixture  before  the  latter  is 
used.  This  is  a  very  old  injection,  and  has  given  great  satisfaction. 

IJ .     Zinci  sulphocarbolatis gr.  i. — iv. 

Aquae f  i. 

M. 

is  another  injection  possessing  about  the  same  qualities  as  the  sulphate 
of  zinc  injections,  but  preferred  by  some  patients. 

IJ  •     Quiniae  bisulph gr.  ij. 

Acid  sulph.  dil nivi. 

Aquae §  i. 

M. 

makes  an  excellent  stimulating  injection. 

3  •     Pulv.  aluminis gr.  v. — x. 

Aquae 3  i. 

M. 

is  a  fair  astringent  injection;  a  better  one  is  a  solution  of  tannin,  at 
about  the  same  strength.  The  tannin  solution,  however,  has  the  great 


268 


THE    VENEKEAL    DISEASES. 


disadvantage  of  staining  the  linen  a  brownish  color,  which  will  not  wash 
out,  and  its  use,  therefore,  calls  for  much  care. 


M. 


Zinci  permanganatis  ..........................    gr.  ^  —  ij. 

Aquae  ................................... 


1 1. 


is  an  excellent  injection  at  the  end  of  the  gleety  stage  of  a  gonorrhoea. 

This  injection  is  of  a  beautiful  purple  color  and  stains  the  linen,  but  the 

stain  washes  out. 

Injections  of  iron  are  sometimes  highly  praised;  the  subsulphate,  half 

a  drachm  in  six  ounces  of  water,  is  well  spoken  of  by  Bumstead,  as  a 
strong  astringent  at  the  end  of  the  gleety  stage.  This 
also  stains  the  linen. 

Ricord's  red  wine  injection  must  not  be  overlooked. 
Some  patients  use  it  with  great  apparent  good  effect.  It 
is  supposed  to  be  tonic  as  well  as  astringent  to  the  urethra. 
It  is  simply  a  mixture  of  ordinary  claret  with  rose-water 
(or  common  water),  commencing  in  the  proportion  of  two 
parts  of  the  latter  to  one  of  the  former,  and  gradually  in- 
creasing the  relative  strength  of  the  wine,  using  of  course, 
the  same  brand  of  red  wine  constantly.  Finally,  pure  wine 
can  be  used. 

Another  pleasant  tonic  and  gently  astringent  injec- 
tion is  tea.  Tea  infusion  may  be  used  just  as  it  is  brought 
on  the  table,  undiluted,  black  or  green  tea.  It  is  suitable 
in  chronic  cases  of  thin  gleet,  and  is  clean,  always  at  hand, 
and  much  praised  by  some  patients.  It  is  actually  a  tan- 
nin injection,  but  more  efficacious  by  far  than  a  solution 
of  tannin  of  similar  strength. 

Urethral  suppositories  made  with  cacao  butter  or  gela- 
tin are  dirtier,  and  not  so  useful  as  injections. 

When  ordinary  injections  fail,  deep  urethral  injections 
very  rarely  are  of  any  service.  Nitrate  of  silver  and  strong 
injections  of  tannin  are  sometimes  used  by  the  surgeon 
through  a  deep  urethral  syringe,  a  few  drops  of  the  fluid 
being  deposited  at  that  portion  of  the  canal  whence  the 
discharge  is  presumed  to  flow.  This  plan  cannot  be  gen- 
erally recommended.  The  physician  has  to  administer 
the  injections,  and  as  a  rule  very  little  assistance  is  derived 
from  them.  If  deep  applications  are  to  be  made,  they 
can  be  used  with  much  precision  through  the  tube  of  the 
endoscope,  or  by  means  of  the  cupped  sound. 

The  cupped  sound  (Fig.  26)  explains  itself.  It  is  a 
simple  conical  steel  sound,  with  hollow  cups  in  its  sides, 
into  which  may  be  placed  any  stimulating  paste  or  oint- 
ment desired,  and  the  cups  then  may  be  held  against  the 
area  of  inflammation  at  longer  or  shorter  intervals,  for  a 
FIG.  27.  ^ew  minutes  at  a  time,  and  the  effect  watched. 

Generally,  however,  all  cases  calling  for  deep  injections 

are  either  cases  of  stricture,  or  of  prostatic  surface  inflammation.     In  the 

former  case  the  stricture  should  be  treated;  for  the  latter,  time,  hygiene, 

change  of  air,  and  marriage  are  the  appropriate  remedies,  and  far  more 

serviceable  than  deep  injections. 


TREATMENT  OF  TJRETHRAL  INFLAMMATION  IN  THE  MALE.       269 


One  appliance  of  modern  introduction  calls  for  notice.  It  sometimes 
yields  very  good  results.  I  refer  to  the  instrument  called  the  cold  sound, 
and  described  by  Winternitz,1  of  Vienna.  Fig.  27  represents  the  instru- 
ment, which  is  simply  a  silver  catheter  with  no  eye  and  two  orifices.  The 
instrument  is  divided  down  the  middle  internally  by  a  partition,  which 
does  not  extend  quite  to  the  break,  and  the  two 
canals  therefore  communicate  freely  at  the  tip 
of  the  instrument.  To  use  the  instrument  it  is 
only  necessary  to  attach  a  fountain  syringe 
containing  water  at  the  desired  temperature 
to  one  nozzle,  and  a  piece  of  rubber-tubing  to 
the  other.  The  catheter  is  then  introduced 
past  the  seat  of  the  urethral  irritation,  and 
the  fountain  syringe  elevated  so  that  there  may 
be  a  continuous  flow  of  water  from  the  syringe 
down  one  side  of  the  silver  catheter  and  up  the 
other  through  the  rubber  tube,  and  into  a  re- 
ceptacle placed  conveniently  to  receive  it. 

This  instrument  has  been  used  in  cases  of 
neuralgia  of  the  urethra,  nocturnal  pollution, 
and  gleet.  I  have  not  thus  far  derived  much 
benefit  from  it,  excepting  in  the  last-named 
condition.  In  gleet  due  to  a  flabby,  atonic 
state  of  the  urethra,  and  not  dependent  upon 
stricture,  I  believe  this  instrument  to  possess 
value.  Winternitz  uses  it  with  a  certain  graded 
diminution  of  the  temperature  of  the  water 
employed.  I  have  not  found  any  advantage  in 
this  plan,  but  have  adopted  the  simpler  ex- 
pedient of  using  water  at  the  temperature  of 
melting  ice,  and  letting  it  flow  slowly  through 
the  canal  during  five  minutes  on  an  average. 
On  several  occasions  I  have  obtained  an  ex- 
cellent result,  but  this  method  of  treatment, 
as  may  be  said  of  all  the  others  advised  for 
gleet,  will  not  cure  every  case. 

Finally,  in  cases  of  a  gleety  termination  to 
a  gonorrhoeal  flow,  where  the  discharge  will  not 
cease  under  the  means  employed  and  there  is  no 
stricture,  pressure  exercised  by  the  passage  very  gently,  twice  a  week, 
of  a  full-sized  steel  sound,  will  often  promptly  terminate  the  case. 

The  dressing's  of  the  penis,  when  the  urethral  discharge  is  abundant, 
become  a  matter  of  importance.  Some  patients  prefer  to  wrap  the  penis 
up  in  old  muslin,  retaining  the  latter  with  a  light  elastic  band;  but  this  is 
apt  to  slip  off  if  the  elastic  be  loose,  or  to  cause  erection  if  it  be  tight,  and 
to  soak  through  sometimes  if  the  discharge  becomes  profuse.  Some  pa- 
tients like  a  towel  folded  once  or  twice,  and  tied  by  a  broad  tape  about 
the  waist,  so  as  to  hang  like  an  apron  over  the  penis.  This  they  tuck 
about  the  organ,  and  let  the  discharge  soak  up  as  it  flows. 

Bumstead  thinks  well  of  drawers  cut  like  swimming-drawers,  but  this 
will  not  be  enough  protection  when  the  flow  is  quite  free. 

One  of  the  nicest  dressings  is  what  is  known  as  a  penis  suspensory. 


Fio.  28. 


Berliner  klin.  Wochenschrift,  July  9,  1877. 


270 


THE    VENEREAL    DISEASES. 


Fig.  28.  It  is  simply  a  waist-band  holding  a  stiff  little  hoop,  large  enough 
for  the  penis  to  pass  through,  from  the  circumference  of  which  hoop  hangs 

a  fine  rubber  bag.  The  bag  is  loose 
enough  not  to  sweat  the  penis,  and  a  piece 
of  absorbent  cotton  is  placed  in  the  bottom 
of  the  bag  to  soak  up  all  discharges.  The 
only  objection  to  these  bandages  is  that 
they  are  flimsy  and  perishable. 

Twisting  a  couple  of  sheets  of  thin 
water-closet  paper  about  the  penis  is  an 
efficient  protection  when  the  discharge  is 
light.  The  paper  stays  in  place  much 
better  than  linen  or  muslin. 

Finally,  when  the  discharge  is  quite 
scanty,  it  may,  without  damage,  be  re- 
tained within  the  urethra,  between  the 
different  acts  of  urination.  This  may  be 
readily  accomplished,  when  the  prepuce 
is  long,  by  putting  some  lint  or  cotton 
over  the  meatus,  and  retaining  it  in  place 
by  drawing  the  foreskin  forward  over  it; 
and  when  the  prepuce  is  short,  by  cutting 
in  a  piece  of  old  muslin  about  three  inches 

square  a  hole  suitable  in  size,  to  allow  the  passage  of  the  corona  glandis 
through  it.  The  foreskin  is  drawn  back,  the  glans  penis  inserted  through 
the  hole  in  the  muslin,  and  then  the  foreskin  is  again  drawn  forward, 
retaining  the  muslin,  and  so  puckering  it  up  around  the  meatus  that  the 
patient's  linen  is  certain  to  be  preserved  from  spot. 


TREATMENT    OF    CHOBDEE. 

A  certain  amount  of  chordee  is  unavoidable  in  severe  cases,  and  it  is 
better  for  the  patient  to  endure  it  with  good  grace,  sparing  his  stomach 
any  extra  medication.  He  must  keep  up  his  alkaline  diluents,  and  have 
some  cold  water  near  his  bedside,  or  a  piece  of  cold  metal,  which  he  may 
use  locally  upon  awaking  with  a  painful  erection.  Generally  the  simple 
emptying  of  the  accumulated  urine  in  the  bladder  is  enough  to  cause  the 
erection  to  cease,  and  with  it  the  pain.  The  erection  may  come  on  again 
at  once,  however,  as  soon  as  the  patient  gets  warm  in  bed,  and  it  may  be 
active  enough  to  prevent  sleep.  In  such  case,  medicine  is  called  for. 
Sometimes,  however,  drugs  may  still  be  avoided  by  soaking  the  penis  in 
intensely  hot  water  just  before  retiring,  and  tying  a  towel  around  the 
waist  with  a  knot  in  the  back,  for  cases  in  which  lying  upon  the  back 
brings  on  the  erection. 

When  chordee  is  violent  enough  to  prevent  sleep,  it  is  best  to  com- 
mence with  lupulin  as  follows: 

IJ .     Lupulin 3  jss. 

Ft.  pil.  no.  xx. 

S.  Take  eight  pills  the  first  night.  If  this  does  not  suffice,  take  twelve 
the  second  night.  If  this  does  not  succeed,  fifteen  pills  may  be  taken  at 
a  dose. 


TREATMENT  OF  URETHRAL  INFLAMMATION  IN  THE  MALE.       271 

The  objection  to  lupulin  is  that  it  is  very  bulky,  and  many  patients 
will  not  take  so  many  pills.  The  fluid  extract  is  difficult  to  administer. 
The  tincture  is  objectionable  on  account  of  the  alcohol  it  contains.  More- 
over, lupulin  sometimes  causes  diarrhoea,  and  makes  the  patient's  mouth 
and  stomach  uncomfortable  on  the  following  day.  Sometimes  it  causes  a 
dull  headache. 

Bromide  of  potassium  acts  admirably  upon  some  patients,  but  the  dose 
given  must  be  a  large  one.  Dr.  E.  A.  Banks,  of  this  city,  first  brought 
this  treatment  to  my  notice.  A  drachm  dose  in  solution  of  the  *bromide 
should  be  given  on  retiring,  and  this  must  be  followed  by  another  drachm 
if  the  first  fails  to  attain  the  desired  result. 

The  objection  to  bromide  in  continued  use,  from  night  to  night,  is 
that  it  often  upsets  the  stomach,  if  the  latter  be  delicate.  It  sometimes 
produces  diarrhoea  when  used  in  large  doses,  and  it  sometimes  brings  out 
a  red,  scaly  eruption  upon  the  face,  to  which  patients  decidedly  object. 
Hydrobromic  acid  may  be  used  in  some  cases,  but  the  dose  is  double 
that  of  bromide  of  potassium,  and  the  effect  upon  the  urine  seems  to  be  to 
acidify  it,  which  is  objectionable. 

In  bad  case,  final  recourse  has  to  be  had  to  opium  in  some  form.  It  is 
needless  to  add  that  the  sooner  this  can  be  dispensed  with  the  better. 

Suppositories  of  a  grain  or  more  of  the  watery  extract  of  opium  may 
be  used,  made  up  with  cacao  butter  or  with  wax,  and  introduced  into  the 
rectum  on  retiring.  Codeine,  or  the  meconate  of  morphia  in  camphor- 
water,  may  be  given  at  night,  in  doses  sufficient  to  counteract  the  pain 
when  the  latter  is  very  intense.  A  laxative  should  accompany  the  opiate. 

Dr.  R.  F.  Weir,  of  this  city,  discovered,  while  treating  a  case  of  pre- 
scrotal  urethral  fistula  by  operation,  that  an  elastic  tube  passed  beneath 
the  scrotum  and  penis  prevented  erection  in  the  patient  upon  whom  he 
employed  it;  the  doctor's  object  being  to  keep  urine  from  entering  the 
portion  of  the  urethra  which  had  been  operated  upon — for  the  patient  had 
an  opening  in  the  perineum  also.  I  have  tried  this  expedient  upon  pa- 
tients in  several  cases  of  chordee,  but  I  find  them  rarely  willing  to  submit 
to  sufficient  pressure  from  an  elastic  tube  to  attain  the  desired  result. 
One  patient  stood  the  pressure  well  and  derived  advantage  from  it. 

TBEATMENT    OF    PAI^FIEL    URISTATION. 

Often  the  alkaline  diluents  and  the  sandal-oil  or  copaiba  make  the  pain 
on  urination  tolerable;  but  sometimes  it  is. so  intense  that  the  patient  de- 
mands relief.  This  he  may  sometimes  obtain  by  taking  the  bromide  of 
potassium  in  moderate  quantities,  and  if  the  drug  does  not  disagree  he 
may  continue  it  during  several  weeks.  The  possible  bad  effects  of  a  pro- 
longed use  of  the  bromide  may  be  counteracted  by  combining  it  with  the 
syrup  of  the  bromide  of  iron,  and  the  possible  acidifying  influence  upon 
the  urine  may  be  neutralized  by  the  addition  of  an  alkali  to  the  mixture 
as  follows: 

$ .     Potass,  bicarb 3  iij. 

Potass,  bromid 3  i j- — iv. 

Syr.  ferri  bromid §  ss. 

Syr.  aurantii  corticis 3  iss. 

Aquae q.  s.  ad  3  iij. 

M. 
S.  Teaspoonful  in  water,  three  or  four  times  a  day. 


272  THE    VENEREAL    DISEASES. 

Hyoscyamus  is  a  substance  of  great  value  in  overcoming  ardor  urinae. 
It  may  be  given  in  the  form  of  solid  extract  in  pill,  two  or  three  grains 
three  or  four  times  a  day,  or  in  the  shape  of  tincture,  preferably  combined 
with  liquor  potassae,  as  follows: 

I£ .     Liq.  potassse f  ss. 

Tr.  hyoscyami §  ij. — iij. 

Syr.  zingiberis f  iss. 

Aquae  cinnamomi q.  s.  ad   §  vi. 

S.  Dessertspoonful,  two  or  three  times  a  day,  in  water. 


TREATMENT    OF    RETENTION    OF    URINE    IN    GONORRHCEA. 

A  perfectly  healthy  urethra  may  become  so  much  inflamed  by  gonor- 
rhoea, that,  from  swelling  of  the  prostate  and  (chiefly)  deep  urethral 
spasm,  retention  of  urine  comes  on.  This  result  is  much  more  apt  to  follow 
if  the  urethra  was  the  seat  of  stricture,  more  or  less  tight,  before  the  at- 
tack. Generally,  when  retention  comes  on  during  the  acute  stage  of  a 
gonorrhoea,  the  prostate  may  be  felt  through  the  rectum  to  be  hot  and 
throbbing,  and  the  possibility  of  abscess  of  the  prostate  must  be  kept  in 
view. 

Not  uncommonly  retention  complicating  gonorrhoea  may  be  promptly 
overcome  by  giving  the  patient  a  su*bcutaneous  injection  of  ten  to  fifteen 
minims  of  Magendie's  solution  of  morphine,  and  a  hip-bath  of  water  at  a 
temperature  ranging  between  105°  and  115°  Fahrenheit. 

Pieces  of  ice  may  be  put  into  the  rectum,  and  allowed  to  melt  there, 
according  to  Cazenave's  ingenious  suggestion. 

If  other  means  fail,  a  soft  catheter  will  generally  reach  the  bladder 
without  difficulty  or  danger  If  there  be  abscess  of  the  prostate,  a  long, 
curved  silver  catheter  will  have  to  be  used,  and  this  will  sometimes  punc- 
ture the  abscess  and  evacuate  the  pus,  after  which  the  urine  will  flow 
away  without  assistance. 


TREATMENT    OF    VEGETATIONS. 

Venereal  warts,  as  they  are  commonly  called,  spring  up  readily  in  both 
sexes  about  the  genitals,  if  any  acrid  and  irritating  discharges  are  re- 
tained until  they  have  had  time  to  decompose.  These  warts  are  common 
under  a  tight  prepuce  in  connection  with  gonorrhoea,  as  well  as  with 
chancroid  and  syphilitic  lesions,  and  are  often  found  complicating  bala- 
nitis  when  there  has  been  no  venereal  exciting  cause  whatsoever.  The 
warts  are  not  the  flat,  pedunculated  tubercles  of  syphilis,  but  are  like  seed- 
warts  of  the  hand,  composed  of  pointed,  papillary  prominences,  either 
crowing  up  into  a  raspberry-like  mass,  varying  from  the  size  of  a  pin's 
head  to  that  of  the  end  of  the  thumb,  or  spread  out  in  a  dry,  velvety  way 
over  a  large,  flat  surface.  That  the  surface  is  composed  of  acuminated 
papillae  is  as  obvious  in  one  form  of  the  malady  as  in  the  other. 

Treatment  of  these  warts,  wherever  found  and  however  caused,  is  quite 
simple.  Cleanliness  is  a  great  prophylactic,  and  an  essential  to  radical 
cure.  When  the  general  health  is  low,  cod-liver  oil  and  tonics  are  of  value 
in  obstinate  cases. 

Generally,  local  treatment  is  sufficient,  especially  if  the  warts  be  few 


TEEATMENT  OF  UEETHEAL  INFLAMMATION  IN  THE  MALE.       273 

in  number.  In  such  case  each  separate  wart  may  be  touched  with  pure 
nitric  acid.  This  turns  the  top  of  the  wart  yellow,  and  the  yellow  layer 
may  then  be  picked  off.  The  stump  must  be  again  touched,  and  the  acid 
allowed  to  dry  in.  Another  and  another  yellow  layer  may  have  to  be 
taken  away,  according  to  the  size  of  the  wart.  Finally,  when  the  wart 
has  been  burned  down  even  with  the  surrounding  mucous  membrane, 
one  final  drop  of  acid,  to  destroy  the  hypertrophied  papillae  at  their  very 
foundation,  will  generally  insure  the  patient  against  any  further  return 
of  the  malady  upon  that  particular  site. 

When  there  are  a  number  of  warts  surrounded  by  a  moist  discharge, 
no  local  treatment  is  so  good  as  a  plentiful  and  repeated  dusting  with  dry 
calomel  and  washing  the  surface  daily  with  diluted  Labarraque's  solution. 

When  the  clusters  are  quite  numerous,  perhaps,  more  or  less  dry, 
an  excellent  local  application  is  the  saturated  solution  of  muriate  of  am- 
monia. 

Under  the  same  circumstances,  the  local  application,  plentifully,  of 
the  saturated  solution  of  thuja  occidentalis,  with  ten-  to  sixty-minim  doses 
of  the  same  tincture  internally,  three  times  a  day,  will  often  affect  the 
warts  quite  promptly,  and  cause  their  entire  disappearance. 


TREATMENT    OF    INFLAMMATORY   PHYMOSIS    DUE    TO    GONORRHOEA    AND   TO 
BALANITIS   AND   POSTHITIS. 

Balanitis  and  posthitis  are  best  prevented  as  complications  of  gonor- 
rhoea by  great  cleanliness.  When  they  come  on,  frequent  washings  be- 
come imperative  ;  and  when  the  foreskin  is  too  tight  to  be  drawn  back,  its 
cavity  must  be  thoroughly  syringed  out  several  times  a  day,  with  a  one- 
half  of  one  per  cent,  watery  solution  of  carbolic  acid,  or  with  some  other 
cleansing  fluid.  If  the  foreskin  can  be  retracted,  the  excoriated  surfaces 
may  be  dusted  with  calomel  and  oxide  of  zinc,  in  equal  parts  by  weight, 
and  dressed  with  a  piece  of  prepared  lint  soaked  in  diluted  lead-water  or 
some  astringent  solution,  one  of  the  best  of  which  is  the  following : 

3 .     Vin  aromatic 3  iss. — iv. 

Aquas q.  s.  ad    |  i. 

M. 

If  the  prepuce  be  congenitally  narrow  at  its  orifice,  it  is  well  to  take 
advantage  of  the  opportunity  to  insist  upon  the  propriety  of  slitting  it  up 
along  the  dorsum  if  it  is  short,  of  performing  circumcision  if  it  is  redun- 
dant. In  the  latter  case  care  must  always  be  taken  in  the  adult  that  the 
cutaneous  margin  of  the  circumcised  prepuce  be  amply  loose.  If  it  is  not 
so,  the  cutaneous  raw  circle  must  be  made  larger  by  a  cut  along  the  dorsum 
of  the  penis,  half  an  inch  long  or  thereabouts,  in  order  to  change  the  small 
circle  into  a  larger  oval  before  the  mucous  membrane  is  stitched  to  the 
skin.  A  more  elegant,  but  a  little  more  troublesome  method,  is  to  leave 
the  integument  on  the  dorsum  circular  at  the  cut  edge,  and  to  make  the 
half-inch  incision  along  the  raphe  beneath  the  penis.  Into  the  angle  thus 
opened,  a  triangular  piece  of  the  semi-mucous  membrane  of  the  penis,  in- 
cluding the  frenum,  and  shaped  with  scissors  to  fit  the  gaping  cut,  may  be 
inserted  and  stitched.  The  result  in  cases  operated  on  in  this  way  is  par- 
ticularly satisfactory. 

If  the  prepuce  is  inflamed  and  not  in  a  fit  state  for  operation,  but  yet 
18 


274  THE   VENEREAL    DISEASES. 

phymosed,  mild  injections  of  lead  and  sulphocarbolate  of  zinc  are  appro- 
priate. They  should  be  used  warm. 

Inflammation  of  the  prepuce  involving  its  whole  thickness  is  treated 
by  putting  the  patient  to  bed,  elevating  the  penis  upon  a  compress  placed 
on  the  thigh  or  abdomen  (the  penis  should  never  hang  down  in  these  cases), 
and  dressing  at  first  with  some  soothing  lotion,  like — 

$ .     Liq.  plumbi  subacetat.  dil §  i. 

Spts.  rect 3  i. — ij. 

which  should  be  kept  constantly  applied,  to  be  followed  by  an  astringent, 
such  as  a  solution  of  the  glycerole  of  tannin  in  water,  from  one  to  three  or 
four  drachms  to  the  ounce  of  water.  The  hard  oedema  of  the  prepuce 
sometimes  following  lymphangitis  must  be  left  to  time  to  cure. 

Paraphimosis  complicating  gonorrhoea  is  generally  caused  by  oedema. 
The  deeper  parts  are  not  strangulated  and  not  likely  to  be,  and  there  is 
rarely  any  occasion  to  attempt  to  reduce  the  prepuce.  If  it  is  considered 
desirable  to  replace  the  prepuce,  this  may  be  effected  by  wrapping  up  the 
swollen  member  in  a  rubber  bandage  long  enough  to  squeeze  out  the 
oedema,  after  which  reduction  becomes  quite  easy.  Sometimes  a  few 
coats  of  contractile  collodion  will  keep  down  excessive  oedema  and  com- 
fort the  patient,  and  sometimes  a  rapid  disappearance  of  the  oedema  may 
be  brought  about  by  the  constant  application  of  a  strong  solution  of  tan- 
nin. Should  the  accident  of  positive  strangulation  of  the  penis  occur,  the 
strictured  point  must  be  divided  with  the  knife. 


CHAPTER  III. 

COMPLICATIONS  OF  GONORRHOEA  IN  THE  -MALE. 

Inflammation  of  the  Follicles  of  the  Urethra. — Follicular  and  Peri-Urethral  Abscesses. 
— Gowperit^s. — Inflammation  of  the  Lacuna  Magna. — Death  due  to  Gonorrhoea. — 
Gonorrhoea!  Cystitis. — Gonorrhoea!  Epididymitis. — Sterility  following  Gonorrhceal 
Epididymitis. — Treatment  of  Gonorrhoea!  Epididymitis,  Prophylactic  and  Curative. 
— The  Tobacco  Poultice. — Strapping  the  Testicle. — Chronic  Epididymitis. 

BESIDES  the  common  complications,  chordee,  balanitis,  phymosis,  etc., 
already  detailed  in  the  preceding  chapter,  there  remain  to  be  considered 
inflammation  affecting  the  glands  of  the  urethra,  peri-urethritis,  gonorrhceal 
cystitis,  and  epididymitis. 

Inflammation  of  urethra!  follicles. — The  follicles  of  the  urethra 
always  participate  more  or  less  in  all  acute  inflammations  of  the  canal. 
In  chordee  the  follicles  at  the  affected  spot  are  certainly  involved,  and  are 
probably  the  route  by  which  the  inflammation  reaches  the  deeper  tissues. 
These  mild  inflammations  get  well  spontaneously,  as  a  rule,  when  the  sur- 
face congestion  goes  down. 

In  the  prostate,  however,  this  is  not  always  the  case.  Here  the  irritation 
seems  to  love  to  linger  in  some  cases  after  gonorrhoea,  attended  by  an 
oozing  of  a  gleety  material  from  the  prostate,  perhaps  a  certain  amount 
of  irritability  of  the  bladder,  possibly  pain  during  the  ejaculation  of  the 
spermatic  fluid,  sometimes  pain  on  crossing  the  legs,  on  sitting,  on  jolting. 
The  symptoms  may,  indeed,  much  resemble  those  of  stone  in  severe  cases, 
when  there  is  a  certain  amount  of  surface  thickening  of  the  mucous  mem- 
brane of  the  prostate,  as  well  as  implication  of  its  follicles. 

These  cases  generally  occur  in  broken-down  phthisical  subjects,  or  in 
those  who  inherit  gouty  tendencies. 

Treatment  is  very  ineffective.  Bland  alkaline  drinks,  tonics,  regu- 
larity of  life,  change  of  air,  and  marriage,  are  the  best  means  through 
which  a  final  cure  can  be  reached.  These  patients  often  imagine  they 
have  spermatorrhoea. 

The  same  treatment  applies  when  the  symptoms  show  that  one  of  the 
seminal  vesicles  has  become  the  seat  of  inflammation,  propagated  from  an 
inflamed  urethra. 

There  are  three  other  forms  of  follicular  disease  of  the  male  urethra, 
all  quite  rare,  but  occasionally  occurring  as  complications  to  urethral  in- 
flammation. One  of  these  is  the  cystic  abscess  of  small  size,  sometimes 
encountered  near  the  fossa  of  the  frenum  in  connection  with  gonorrhoea. 
The  tumor  is  round,  hard,  painful,  feeling  like  a  shot  or  a  pea  as  it  moves 
under  the  skin  beneath  the  fingers,  and  connected  to  the  mucous  mem- 
brane of  the  urethra  by  a  long,  thin  peduncle,  the  obliterated  duct  of  the 
gland. 

These  are  little  follicular  abscesses.  They  should  be  cut  out  entire, 
or  at  least  half  of  their  circumference  should  be  cut  away  while  the 
wound  is  left  open  to  granulate. 


276  THE   VENEREAL    DISEASES. 

Inflammation  of  Cowper's  glands,  usually  only  one  at  a  time,  is 
another  follicular  inflammation  of  the  urethra,  but  so  rare  in  connection 
with  urethritis  as  hardly  to  deserve  mention.  The  symptoms  are,  at  first, 
the  appearance  of  a  distinct  hard  swelling  on  one  side  of  the  raphe,  mak- 
ing it  painful  for  the  patient  to  sit  down.  This  soon  changes  into  a  dif- 
fuse inflammatory  swelling  involving  the  perineum  and  scrotum,  more 
prominent  on  that  side  of  the  raphe  upon  which  the  inflammation  began. 

The  treatment  consists  in  poulticing  and  an  early  free  incision,  al- 
though resolution  of  this  form  of  inflammation  has  been  occasionally  noted. 

A  third  form  of  follicular  inflammation  said  to  be  not  uncommon, 
although  I  have  never  been  certain  that  I  could  decide  when  it  existed, 
is  inflammation  of  the  lacuna  magna  upon  the  roof  of  the  urethra. 
Phillips  is  generally  quoted  in  connection  with  this  malady,  and  his 
advice  that  the  pouch  of  the  lacuna  be  slit  up  upon  a  fine  director,  when 
the  malady  can  be  located  at  this  point,  is  generally  endorsed. 

Finally,  peri-urethral  abcesses  are  often  the  result  of  the  spread  of 
inflammation  from  inflamed  follicles  going  on  to  suppuration. 

Peri-urethral  abscess  is  very  rare  with  gonorrhoea.  It  is  much 
more  common  in  connection  with  stricture.  With  the  acute  malady  it 
occasionally  occurs  at  any  point  along  the  urethra,  but  preferably  at  the 
forward  end  near  the  frenum,  or  far  back  near  the  bulb.  Free  opening  of 
these  hard  masses,  well  down  to  the  urethral  mucous  membrane,  before 
suppuration  has  occurred,  is  the  best  treatment.  In  the  perineum  fluctu- 
ation occurs  promptly,  and  it  is  safe  to  wait  for  it,  since  there  is  no  fear 
that  the  urethra  will  be  extensively  denuded  in  this  region.  If  the  abscess 
occurs  witHin  the  capsule  of  the  prostate,  it  generally  opens  into  the  ure- 
thra, or  is  opened  during  catheterism  undertaken  to  relieve  retention. 

Fistula  may  be  left  behind  by  peri-urethral  abscess,  and  a  prolonged 
gleet  by  prostatic  abscess,  unless  the  latter  has  been  detected  through 
the  rectum,  and  opened  through  the  walls  of  the  gut — an  excellent  treat- 
ment whenever  a  point  of  fluctuation  can  be  felt  in  this  region. 

As  an  exceptionally  rare  complication  of  gonorrhoea  may  be  men- 
tioned suppurative  adenitis  in  the  groin.  A  certain  amount  of  tender- 
ness in  the  groin  is  very  common  in  severe  gonorrhoea,  with  more  or  less 
turgescence  of  the  ganglia;  but  suppuration,  although  possible,  is  quite 
uncommon. 

Death  occurring  during  the  course  of  an  acute  gonorrhoea  may  be 
due  to  pyelitis,  Murchison  reports  two  cases,1  or  to  peritonitis  starting 
from  abscess  in  the  seminal  vesicles,  or  to  some  suppurative  inflammation 
deep  among  the  tissues  of  the  pelvis,  and  due  to  gonorrhoea.  Hunter 
alluded  to  this  subject,  and  a  number  of  cases  have  been  reported,  espe- 
cially in  the  French  journals.  Faucon 2  has  written  an  excellent  article 
upon  the  subject  recently. 


GONOBEHtEAL   CYSTITIS. 

An  inflammation  of  the  neck  of  the  bladder  is  apt  to  come  on  in  con- 
nection with  urethritis  under  a  variety  of  circumstances.  It  very  rarely  oc- 
curs spontaneously  during  gonorrhoea.  Generally  some  immediate  exciting 

1  Transactions  of  the  Clinical  Society,  London,  1876,  p.  25. 

*  De  la  pt-ritonite  et  du  masculine  phlegmon  sous-peritoneal  d'origine  blennorrha- 
gique.  Archives  gen.,  1877,  Oct.,  p.  385,  and  Nov.,  p.  549. 


COMPLICATIONS    OF    GONORRHOEA   IN   THE    MALE.  277 

cause  produces  it.  Among  the  most  common  of  these  are  the  use  of 
strong  injections,  especially  if  thrown  too  deeply  into  the  canal;  strong 
and  continued  sexual  excitement,  or  attempts  at  intercourse  during  a 
gonorrhoea;  excess  in  physical  exertion  of  any  sort;  abuse  of  liquor;  ex- 
cess in  the  use  of  cubebs,  turpentine,  or  cantharides  for  the  cure  of  the 
gleety  stage  of  gonorrhoea;  the  use  of  instruments  in  the  urethra  at  too 
early  a  date  in  the  course  of  the  attack,  especially  if  there  be  any  lack  of 
perfect  gentleness  in  manipulation  during  such  instrumentation. 

All  of  these,  and  certain  other  analogous  causes,  are  sufficient  to  ex- 
cite gonorrhoeal  cystitis  in  a  patient  having  anurethral  discharge,  although 
the  discharge  itself  may  have  become  very  mild  and  gleety,  and  much 
the  more  so  when  the  discharge  is  intense.  The  same  exciting  causes  are 
also  sometimes  productive  of  cystitis  when  the  gleety  urethral  discharge 
is  due  to  stricture,  and  not  very  infrequently  an  attack  of  mild  cystitis 
comes  on  in  a  patient  with  a  diseased  urethra,  the  exact  immediate  cause 
of  which  cannot  be  determined. 

Gonorrhceal  cystitis  is  not  commonly  encountered  until  the  urethral 
discharge  has  been  active  for  several  weeks. 

Symptoms. — As  the  cystitis  comes  on,  the  patient  at  first  makes 
•water  a  little  more  often  than  usual  by  day  (sleeping  perhaps  through 
the  whole  night),  and  the  urethral  discharge  lessens,  so  that  he  congratu- 
lates himself  that  he  is  getting  well.  Soon,  however,  he  finds  that  the 
calls  to  urinate  become  more  imperative.  On  the  call  he  must  find 
speedy  relief,  or  his  bladder  will  contract  partially  in  spite  of  his  efforts 
to  restrain  it,  and  he  may  wet  himself.  Then  follows  pain  on  urination, 
and  a  sharp,  grinding,  bearing-down  pain  following  each  act  of  urination, 
due  to  the  fact  that  the  empty  bladder  continues  to  contract,  and 
squeezes  its  own  tender  neck. 

From  this  time  on  there  is  a  constant  sense  of  weight,  a  dull  pain  over 
the  pubic  symphysis,  more  or  less  heat  and  discomfort  in  the  perineum, 
a  constant  sensation  of  fulness  of  the  bladder,  calling  for  repeated  and 
unavailing  straining  to  pass  water,  the  best  efforts  culminating  in  a  spurt 
of  only  a  few  drops  of  turbid  urine  full  of  pus  and  often  tinged  with 
blood. 

Before  this  state  has  been  reached  the  patient  has  become  quite  fever- 
ish, with  dry  tongue,  parched  lips,  and  constipated  bowels.  One  peculiar 
quality  of  the  fever  attending  inflammation  of  the  bladder,  rarely  lacking 
in  a  well-marked  case,  is  very  serious  depression  of  spirits.  Patients  with 
this  malady  are  often  more  depressed,  more  anxious,  less  manageable  than 
if  they  had  a  far  more  serious  disease,  although  the  fever  itself  very  rarely 
runs  high.  The  only  consolation  that  they  find  is  in  the  fact  that  their 
discharge  has  ceased,  a  comfort  to  which  they  have  no  valid  claim,  since 
a  return  of  the  show  of  pus  at  the  meatus  is  generally  one  of  the  first 
and  most  certain  signs  that  the  cystitis  has  begun  to  get  well. 

Gonorrhosal  cystitis  generally  gets  perfectly  well  in  a  period  varying 
from  a  few  days  in  mild  cases,  up  to  a  couple  of  weeks,  or  even  several 
months,  in  bad  cases.  Sometimes  permanent  irritability  is  left  behind,  a 
circumstance  which  lends  a  respectability  to  the  malady  it  would  not  oth- 
erwise possess. 

Treatment. — When  a  patient  with  an  urethral  discharge  commences 
to  make  water  too  often,  the  first  thing  to  do  is  to  search  for  the  exciting 
cause  and  stop  its  action  if  possible.  Give  up  injections  and  make  the  pa- 
tient keep  as  quiet  as  possible  in  all  physical  respects.  One  precaution 
is  this:  the  bladder  should  not  be  entirely  emptied  at  any  act  of  urina- 


278  THE    VENEREAL   DISEASES. 

tion.  Many  patients  cannot  arrest  the  stream  at  will  when  the  neck  of 
the  bladder  is  inflamed;  but  the  attempt  should  always  be  made,  and 
when  it  can  be  accomplished  considerable  benefit  may  be  expected  from 
this  simple  precaution.  Much  of  the  distressing  pain  after  urinating  can 
be  averted  if  half  an  ounce  of  urine  is  left  in  the  bladder;  and  in  any  case, 
if  the  patient  must  go  on  urinating  until  the  bladder  is  empty,  he  should 
be  told  on  no  account  to  repeat  the  spasmodic  voluntary  effort  of  expell- 
ing the  last  few  drops  from  the  urethra  which  his  malady  inclines  him  to 
do.  Once  this  "coup  de  piston"  may  be  made,  but  it  should  not  be  re- 
peated. 

In  mild  cases,  rest  upon  the  back  may  be  all  that  is  required  in  the 
way  of  treatment,  except  the  use  of  hot  water,  preferably  in  a  rubber 
bottle,  which  affords  considerable  comfort  when  placed  (partly  filled,  so  as 
not  to  be  too  heavy)  over  the  bladder  or  against  the  perineum,  especially 
if  the  hips  be  kept  raised  slightly  above  the  level  of  the  shoulders. 

Any  stimulating  balsam  or  tincture  which  is  being  given  for  the 
gonorrhoea  should  be  stopped  at  once.  The  alkaline  diluent  should  be 
continued,  and  bland  drinks,  like  flaxseed  tea,  elm-bark  decoction,  infu- 
sions of  triticum  repens,  buchu,  arenaria  rubra,  etc.,  to  afford  the  patient 
a  little  mental  comfort,  for  certainly  they  do  not  do  much  good  physi- 
cally, excepting  in  so  far  as  they  are  mildly  diuretic. 

Bathesda  mineral  water  drunk  freely  is  unquestionably  of  value  in 
these  cases,  and  an  exclusive  milk  diet  has  a  peculiar  merit.  The  latter 
must  be  accompanied  by  enough  of  some  mild  vegetable  laxative  to 
overcome  its  constipating  tendency.  If  it  purges,  as  is  sometimes  the 
case,  skimmed  milk  may  be  substituted  for  whole  milk.  A  gallon  a  day 
is  full  diet  for  a  healthy  man.  If  so  much  can  be  managed  by  the  stom- 
ach, nothing  else  whatever  need  be  given  either  to  eat  or  to  drink. 

All  those  articles  of  food  and  drink  which  were  condemned  in  the  diet- 
etic section  on  the  treatment  of  gonorrhoea  must  be  equally  avoided  here 
(page  260). 

Hot  hip-baths  are  of  considerable  service  in  this  affection.  The  heat 
of  the  bath  should  range  in  the  region  of  110°  Fahrenheit,  the  pelvis  should 
be  covered  by  the  water-line,  and  the  bath  be  not  longer  than  three  or 
four  minutes  in  duration.  Such  baths  may  be  repeatedly  taken  every 
few  hours  during  the  day  when  they  afford  relief. 

As  for  medicines,  anodynes  hold  the  first  rank.  The  frequency  of 
urination  must  be  stopped,  whatever  happens.  The  old  combination: 

IJ  •     Liq-  potassae 3  ss. 

Tr.  hyoscyami §  iss. 

Syr.  aurantii  cort 3  i. 

M.    ' 
S.  Teaspoonful  in  water  every  four  hours. 

will  give  relief  in  mild  cases.  The  strength  of  the  alkali  in  this  prescrip- 
tion may  be  decreased,  and  that  of  the  hyoscyamus  perhaps  increased 
with  advantage.  Hyoscyamus  may  be  used  alone,  as  tincture,  in  drachm 
doses  several  times  a  day,  with  the  happiest  effect  in  the  cases  in  which 
it  agrees.  It  must  be  remembered  that  hyoscyamus  sometimes  causes  de- 
lirium. 

When  mild  measures  of  this  sort  fail  to  control  the  frequency  of  uri- 
nation, a  positive  anodyne  must  be  employed.  Half-grain  or  whole  grain 
suppositories  of  the  watery  extract  of  opium,  with  a  third  to  the  half  of 


COMPLICATIONS    OF    GONOERHCEA   IN   THE   MALE.  279 

a  grain  of  the  extract  of  belladonna,  may  be  used  and  repeated  often 
enough  to  keep  the  intervals  of  urination  two  hours  long.  The  belladonna 
sometimes  disagrees. 

Powders  of  morphine,  like  the  following: 

]J .     Morph.  bimeconatis gr.  vij. — xiv. 

Gum  camphor 3  i. 

Resinae  jalapae gr.  vj. — x. 

Pulv  sacch.  alb 3  ss. 

M.     Ft.  chart,  no.  xx. 
Put  into  waxed  paper. 

S.  One,  as  required. 

• 

may  be  used  for  the  same  purpose,  to  keep  the  intervals  of  urination  two 
hours  long  by  daylight,  or  an  analogous  liquid  preparation: 

IjL     Elix.  opii  (McMunn) 3  vi. — xij. 

Elix.  rhamni  frangulae §  ss. — iss. 

Syr.  aurantii q.  s.  ad  |  iij. 

M. 
S.  Teaspoonful,  as  required. 

By  persistence  in  these  means,  the  pain,  the  tenesmus,  and  the  fre- 
quency of  urination  will  gradually  subside,  and  the  discharge  begin  to 
reappear  at  the  meatus.  For  this  return,  some  mixture  of  copaiba  (p.  263) 
should  be  used  internally,  since  the  effect  of  this  drug  upon  the  bladder 
is  often  also  quite  beneficial. 

The  patient  must  resume  his  habits  of  life  slowly,  and  conduct  the 
subsequent  treatment  of  his  gonorrhoea  with  great  circumspection. 


GONOEBH(EAL  EPIDIDYMITIS. 

Epididymitis  occurs  quite  frequently  as  a  complication  of  gonorrhoea. 
Fournier  places  its  frequency  as  high  as  twelve  per  cent.,  and  Sigmund  at 
between  six  and  eight,  believing  that  the  left  testicle  is  more  often  at- 
tacked than  its  fellow.  Like  gonorrhoeal  cystitis,  it  may  come  on  in  re- 
gular sequence  as  a  result  of  the  gradual  spread  downward  of  the  urethral 
inflammation  to  the  mouths  of  the  ejaculatory  ducts.  Its  most  common 
date  of  appearance,  during  the  course  of  a  gonorrhoea,  is  the  end  of  the 
third  week. 

The  date  of  appearance  of  epididymitis,  however,  is  by  no  means  fixed. 
I  have  seen  it  come  on  during  the  first  few  days,  as  a  result  of  irritating 
injections  used  to  abort  a  gonorrhoea,  and  it  may  be  encountered  at  any 
period  later,  or  even  at  any  time  afterward  during  life,  if  stricture  be  left 
behind  by  the  gonorrhoea.  Stricture  of  the  urethra,  or  rather  the  irritation 
so  constantly  existing  behind  it,  is  a  fertile  source  of  epididymitis. 

Generally,  epididymitis  is  due  to  some  direct  exciting  cause  over  and 
above  the  general  inflammation  of  the  urethra.  Among  such  immediate 
causes  may  be  enumerated  most  of  those  irritants,  general  and  local,  which 
have  been  enumerated  already  as  being  capable  of  lighting  up  cystitis  in 
a  patient  with  gonorrhoea,  such  as  injections  too  irritating  in  quality  or 
thrown  too  deeply  into  the  canal  ;  the  passage  of  a  sound  or  other  instru- 
ment, for  exploratory  or  other  purposes,  down  a  urethra  which  is  the  seat 


280  THE   VENEREAL   DISEASES. 

of  surface  inflammation;  sexual  irritation  of  any  sort;  drinking;  violent 
exercise,  which  is  generally  believed  to  act  by  directly  damaging  the  tes- 
ticle mechanically,  and  thus,  as  it  were,  calling  down  the  inflammation 
from  the  urethra.  Hence  the  prophylactic  importance  of  a  snug  suspen- 
sory bandage. 

Symptoms. — When  acute  epididymitis  is  about  to  attack  a  healthy 
testicle,  it  generally  takes  at  least  twenty -four  hours  to  get  fairly  under 
way.  Sometimes  signs  of  warning  may  be  appreciated  by  the  well-in- 
formed observer,  even  earlier  than  twenty-four  hours  before  the  testicle 
begins  to  swell.  The  first  sign  is  generally  an  uneasiness  referred  to  the 
depths  of  the  groin,  upon  the  side  about  to  become  affected,  with  a 
sense  of  weight  and  uneasiness  in  the  testicle  of  that  side,  which  is  usually 
already  somewhat  over-sensitive  to  handling.  With  these  symptoms  there 
may  be  some  general  malaise,  a  little  constipation,  slight  headache,  a  tri- 
fling fever. 

These  symptoms  are  quite  apt  to  come  on  in  the  afternoon  after  a  day 
of  ordinary  exercise.  I  cannot  recall  a  case  in  which  the  first  signs  of 
epididymitis  appeared  early  in  the  day,  when  that  epididymitis  appeared 
in  due  course  as  a  complication  of  gonorrhoea. 

The  patient  naturally  keeps  still  with  the  pain  in  his  groin  or  testicle, 
and  the  rest  of  an  evening,  or  a  night,  or  both,  often  makes  him  so  com- 
fortable that,  upon  awaking  the  next  morning,  he  may  not  be  con- 
scious that  he  has  any  unusual  pain  until  he  is  upon  his  feet — possibly 
not  then — for  there  is  no  disease  more  apt  than  this  one  to  stop  unexpect- 
edly at  any  point  in  its  course,  and  thus  to  justify  the  most  varied 
means  of  treatment.  Indeed,  after  quite  a  marked  prodromal  stage,  a 
night's  rest  sometimes  dissipates  the  pains,  and  the  patient  becomes  and 
remains  well. 

This  fortunate  result  is  rare.  Generally,  as  the  day  goes  on,  the  pain 
in  the  groin  becomes  more  intense,  the  testicle  rapidly  or  gradually  grows 
heavy,  hot,  and  painful,  the  enlargement  commencing  at  the  lower  in 
the  back  part.  There  may  be  a  sharp  chill,  followed  by  intense  fever, 
nausea,  headache,  and  vomiting.  Constipation  is  uniform,  and  sometimes 
there  is  a  tendency  to  frequency  in  urination,  with  more  or  less  pain  in 
the  act. 

Now  the  malady  is  fairly  under  way,  and  the  testicle  continues  rapidly 
to  swell.  The  flow  of  pus  from  the  urethra  becomes  diminished,  or  stops 
entirely,  to  the  delight  of  the  patient,  who  indulges  in  the  vain  hope  that 
that  part,  at  least,  of  his  misfortunes,  at  last  is  over.  It  is  a  kindness  to 
undeceive  him,  and  let  him  know  that  his  relief  from  urethral  trouble  is 
only  transitory,  and  that  his  discharge  will  surely  return  as  the  inflamma- 
tion in  the  testicle  subsides. 

The  fever  increases,  at  first,  as  the  testicle  swells,  and  to  the  intense 
and  increasing  pain  in  the  groin  is  added,  often,  an  intolerable  splitting 
pain  in  the  back,  low  down.  Meantime  the  testicle  has  increased  in  all 
its  dimensions.  A  little  fluid  generally  collects  in  the  tunica  vaginalis, 
keeping  the  testicle  oval  in  shape  as  it  increases  in  size.  The  scrotum 
gets  red  and  hot,  and  is  sometimes  the  seat  of  a  very  considerable  cedem- 
atous  effusion. 

The  intensity  of  the  symptoms,  and  the  height  to  which  the  inflam- 
mation is  to  run,  vary  greatly  in  different  cases.  There  may  be  nothing 
more  than  a  little  tension  of  the  testicle,  most  marked  posteriorly,  lasting 
only  a  few  days,  and  totally  relieved  by  the  recumbent  posture,  if  the  tes- 
ticle be  at  the  same  time  elevated  and  supported.  On  the  other  hand, 


COMPLICATIONS    OF    GONOEEHCEA   IN   THE   MALE.  281 

the  suffering  may  be  intense,  the  scrotum  hot,  red,  and  shining,  the  pain 
in  the  groin  and  back  excruciating,  the  tunica  vaginalis  tense  and  full  of 
fluid,  the  substance  of  the  whole  testicle  seemingly  in  a  state  of  most 
active  inflammation,  and  this  condition  is  not  relieved  either  by  position 
or  by  support  to  the  testicle. 

First  attacks  of  epididymitis,  like  first  attacks  of  gonorrhrea,  are 
usually  much  more  formidable  in  their  symptoms  than  subsequent  visita- 
tions of  the  same  malady.  In  the  subacute  form  of  epididymitis,  espe- 
cially in  a  testicle  which  has  been  the  seat  of  former  attacks,  the  whole 
malady  may  consist  in  a  hard  lump,  which  appears  at  the  globus  minor 
or  major,  attended  by  more  or  less  pain,  dragging,  and  constitutional 
symptoms.  This  lumpiness  usually  remains  long  present,  perhaps  for 
months,  or  even  years,  becoming,  finally,  almost  or  quite  insensitive, 
and  not  responding  at  all  to  medication. 

In  the  acute  cases  it  generally  takes  from  two  days  to  a  week  for  the 
increase  in  size  of  the  testicle  to  reach  its  height,  after  which  the  swelling 
goes  down — at  first  slowly,  then  quite  promptly,  so  that  in  ten  days  or 
two  weeks,  under  treatment,  it  may  be  counted  upon  with  reasonable 
certainty  that  the  most  desperate  case  will  be  practically  well — that  is, 
free  from  pain  to  such  an  extent  that  it  may  be  supported  in  a  suspen- 
sory bandage,  or  at  least  strapped,  and  thus  the  patient  be  allowed  to 
get  about  in  comfort. 

Sometimes,  after  an  acute  attack,  a  chronic  induration  of  the  epididy- 
mis  remains  behind  for  an  indefinite  period.  Such  testicles  are  rather 
prone  to  relapse.  The  cord  may  become  involved,  and  the  testicle  itself 
become  pseudo-tubercular,  or  even  tubercular. 

Sterility  due  to  ordinary  inflammatory  epididymitis  calls  for 
a  few  words  of  notice  here.  An  acute  attack  of  the  affection,  if  it  passes 
over  within  a  reasonable  time,  leaves  no  injury  to  the  epididymis  behind 
it;  but  the  subacute  attacks — those  characterized  by  localized  large  nodu- 
lar developments  in  the  tail  or  head  of  the  epididymis — are  apt  to  fail 
to  get  entirely  well,  and  as  a  consequence  the  convoluted  tube  consti- 
tuting the  epididymis  becomes  obliterated  at  the  point  occupied  by  the 
nodule,  and  the  passage  of  spermatozoa  through  it  becomes  mechanically 
impossible. 

The  quality  of  the  inflammation  in  epididymis  seems  to  be  plastic 
rather  than  catarrhal,  although  it  commences  in  the  lining  membrane  of 
the  tube  of  the  epididymis.  The  calibre  of  the  tube  becomes  filled  up 
as  the  morbid  process  advances,  and  the  atmosphere  of  connective  tissue 
in  which  the  tubes  lie  becomes  the  seat  of  a  similar  plastic  inflammation. 
This  process  thickens  the  whole  epididymis  by  new  connective-tissue  de- 
posits, and  fuses  together  into  a  solid  mass  the  convolutions  of  the  canal 
of  the  epididymis.  The  canal  shows  irregular  dilatations  and  contractions 
at  the  seat  of  the  lesion  ;  granulo-fatty  degeneration  may  subsequently 
attack  the  whole  mass,  reducing  it  to  a  cheesy  condition,  in  which  even 
the  contour  of  the  tube  of  the  epididymis  cannot  be  made  out.  The 
name  of  Gosselin  is  generally  coupled  with  this  subject,  since  his  investi- 
gations went  far  to  clear  up  the  pathology  of  chronic  gonorrhreal  epi- 
didymitis and  to  demonstrate  the  mechanical  cause  of  the  sterility  which 
was  known  to  exist  in  some  of  these  cases  after  both  testicles  had  been 
the  seat  of  the  disease.  Gosselin  pointed  out  that  localized  epididymitis 
of  the  tail  of  the  testicle  was  more  apt  to  produce  sterility  than  when 
the  head  of  the  epididymis  alone  was  involved  in  the  disease,  the  reason 
being  that  many  tubes  unite  to  form  the  globus  major,  while  fhe  globus 


282  THE    VENEREAL   DISEASES. 

minor  is  composed  of  the  convolutions  of  a  single  tube — and  unfortu- 
nately  the  globus  minor  is  the  peculiar  seat  of  election  of  this  malady. 

The  sterility  encountered  after  gonorrhceal  epididymitis  is  only  present 
when  both  testicles  have  been  diseased,  and  not  necessarily  then.  This 
sterility  has  no  connection  with  impotence.  The  patient's  virile  powers 
are  as  strong  as  ever,  his  sexual  act  perfect,  his  ejaculation  satisfactory 
and  full,  and  the  testicle  does  not  remain  painfully  swollen  after  sexual 
contact.  Yet  the  fluid  ejaculated  is  not  healthy  sperm.  It  has  the  sper- 
matic odor,  but  is  watery  in  quality,  and  apparently  composed  entirely 
of  fluids  from  the  seminal  vesicles  and  from  the  prostatic  follicles,  for  the 
most  careful  microscopic  examination  has  failed  to  detect  any  spermatozoa 
in  it.  Consequently,  such  a  patient  is  necessarily  sterile,  although  he  is 
not  at  ill  impotent. 

The  treatment  of  this  condition  is  unsatisfactory.  It  is  believed 
that  iodide  of  potassium,  mild  mercurials,  and  cod-liver  oil  internally, 
hasten  absorption;  but  it  is  not  well  to  place  much  faith  in  the  curative 
action  of  these  drugs.  Time  will  effect  a  cure  in  some  cases;  it  will  fail 
in  others.  Possibly  long-continued  pressure  might  assist  absorption  and 
help  to  clear  the  tubes. 

The  most  important  medical  bearing  which  a  knowledge  of  this  gon- 
orrhceal sterility  possesses  is  in  its  relation  to  the  question  of  marriage. 
Many  patients  know  that  prolonged  chronic  epididymitis  on  both  sides  is 
liable  to  entail  the  loss  of  the  power  of  procreation,  and  before  marriage 
such  a  man  may  come  to  demand  an  opinion  as  to  his  capacity  to  beget 
a  child.  The  only  grounds  upon  which  such  an  opinion  can  be  honestly 
rendered  are  (presumptive)  the  existence  of  a  lumpy  indurated  condition 
of  the  epididymis  on  both  sides,  and  (positive)  the  entire  and  continued 
absence  of  spermatozoa  from  the  spermatic  fluid. 


TREATMENT   OF   EPIDIDYMITIS. 

The  prophylactic  treatment  of  epididymitis  is  very  simple.  A 
snug  suspensory  bandage  should  be  worn,  and  all  such  exercise  as  might 
jolt  or  bruise  the  testicle  must  be  strictly  enjoined.  The  patient  should 
be  kept  particularly  quiet  during  the  acuter  periods  of  the  urethral  dis- 
charge, and  cautioned  against  the  least  approach  to  sexual  excitement. 
All  those  articles  of  food  or  drink  which  are  known  to  increase  the  inten- 
sity of  the  urethral  inflammation  also  tend  to  produce  epididymitis,  and 
must  be  avoided;  and  much  care  is  necessary  in  the  selection  of  proper  in- 
jections, as  well  as  in  the  manner  of  administering  the  latter.  Finally, 
and  above  all,  great  circumspection  must  be  exercised  in  using  a  bougie 
or  sound  for  the  cure  of  a  retiring  gonorrhosa.  The  patient  should  be 
prepared  for  the  first  introduction  of  such  an  instrument  by  taking  an  al- 
kaline diuretic  for  at  least  twenty-four  hours  beforehand,  and  it  is  better, 
on  the  first  introduction  of  an  instrument,  not  to  pass  it  entirely  into  the 
bladder,  but  only  into  the  membranous  urethra.  The  time  selected  for 
the  passage  of  an  instrument  for  the  first  time  should  be  late  in  the  after- 
noon or  in  the  evening,  and  the  patient  should  remain  quietly  at  home 
during  the  evening  and  night.  By  the  exercise  of  these  precautions,  it 
will  rarely,  if  ever,  be  possible  for  the  patient  to  accuse  his  surgeon  of  be- 
ing the  immediate  exciting  cause  of  his  swelled  testicle. 

The  curative  treatment  of  epididymitis  varies  somewhat  with  the 
grade  of  intensity  of  the  inflammation.  During  the  premonitory  twenty- 


COMPLICATIONS    OF    GONORKHCEA    IN    THE    MALE.  283 

four  hours,  when  the  only  complaint  is  of  a  slight  weight  «or  dragging  at 
the  cord  in  the  groin,  with  perhaps  some  discomfort  in  the  testicle  and  a 
pain  in  the  back,  it  is  proper  to  put  the  patient  immediately  to  bed  upon 
his  back,  to  administer  a  brisk  laxative,  and  to  sling  the  testicle  well  up 
so  that  the  cord  may  be  entirely  relieved  from  its  weight,  while  the  return 
circulation  from  the  testicle  is  favored  by  gravity. 

This  slinging-up  of  the  testicle  is  a  most  important  matter  during 
all  stages  of  the  treatment  of  the  malady  under  consideration.  It  can- 
not be  effected  by  means  of  the  suspensory  bandage.  Such  a  bandage 
lets  the  testicle  drop  between  the  thighs,  and,  although  it  is  very  use- 
ful in  the  erect  posture,  it  loses  its  value  entirely  when  the  patient  lies 
down. 

An  excellent  means  of  suspending  the  testicles  is  that  employed  in 
most  hospitals.  It  is  quite  effective,  but  is  unfortunately  dirty,  and  con- 
fines the  thighs  to  such  an  extent  that  most  private  patients  will  not  en- 
dure it.  In  some  cases,  however,  the  method  is  very  applicable.  It  con- 
sists simply  in  cutting  a  strip  of  ordinary  adhesive  plaster,  four  or  five 
inches  broad,  and  long  enough  to  stretch  from  one  side  to  the  other  over 
the  tops  of  the  two  thighs,  just  beneath  the  scrotum,  as  the  patient  is  lying 
down.  It  is  applied  by  being  fastened  securely  in  place,  the  adhesive 
side  sticking  to  the  skin  on  the  outer  aspect  of  both  thighs  as  they  lie 
close  together,  the  scrotum  and  inflamed  testicle  meantime  having  been 
drawn  well  up  out  of  the  way,  to  be  afterward  gently  deposited  upon  the 
tense,  smooth,  dry  table,  formed  between  the  thighs  by  the  non-adhesive 
side  of  the  plaster. 

The  plaster  is  dirty,  the  legs  are  constrained,  the  top  of  the  plaster 
sometimes  cuts  into  the  root  of  the  scrotum;  but  the  bandage  does  not 
slip,  and  the  support  is  quite  efficient. 

The  best  method  of  making  support,  and  one  which  applies  to  all  cases, 
whether  or  not  poultices  or  other  dressings  are  to  be  used,  is  the  follow- 
ing: a  large  handkerchief  is  obtained — preferably  of  silk.  This  is  to  be 
folded  into  a  triangle.  At  the  centre  of  the  long  side  of  this  double  tri- 
angle, exactly  opposite  the  right  angle,  a  piece  of  tape  about  three  feet 
long  is  to  be  sewed.  An  ordinary  stiff  roller-bandage,  long  enough  to  en- 
circle the  waist,  completes  the  apparatus,  which  is  to  be  arranged  as  fol- 
lows: the  roller-bandage  is  drawn  quite  snugly  around  the  waist  above 
the  flare  of  the  pelvic  bones,  and  secured  by  safety-pins  or  by  needle  and 
thread.  Then  the  patient  is  instructed  to  hold  the  testicles  and  scrotum 
well  up  above  and  over  the  symphysis  pubis.  The  centre  of  the  long  side 
of  the  triangular  silk  handkerchief,  marked  by  the  tapes,  is  now  placed  in 
the  perineum,  well  up  against  the  root  of  the  scrotum,  and  one  end  of  it 
is  carried  up  on  either  side  along  the  fold  of  the  groin,  under  the  roller- 
bandage  and  over  the  same,  after  which  both  these  ends  are  drawn  upon, 
so  as  to  make  the  long  side  of  the  triangle  sufficiently  tense  under  the 
scrotum,  and  then  the  ends  are  fastened  into  place  with  large  safety-pins. 
Finally,  the  patient  rolls  on  his  side,  and  one  of  the  tapes  carried  between 
the  nates  and  under  the  roller-bandage,  at  the  middle  of  the  back,  is 
knotted  to  its  fellow  in  such  a  way  as  to  keep  the  perineal  portion  of  the 
handkerchief  a  fixed  point.  The  right  angle  of  the  triangular  handker- 
chief is  to  be  loosely  pinned  up  against  the  roller-bandage  in  front,  to  re- 
tain in  place  any  dressing  which  may  be  put  upon  the  testicle. 

A  bandage  well  arranged  as  above  directed  cannot  slip,  and  gives 
more  comfort  than  any  other  appliance  with  which  I  am  familiar.  All 
applications  to  the  testicle  may  be  made  by  its  aid,  excepting  ice,  and  my 


284  THE   VENEREAL    DISEASES. 

experience  has  caused  me  to  condemn  ice  as  a  local  application  in  all  con- 
ditions of  impending  or  actual  epididymitis. 

Certain  authorities  advise  ice,  and  its  application  is  very  simple.  It 
is  only  necessary  to  separate  the  thighs  and  place  the  inflamed  testicle 
upon  a  suitable  cushion,  after  which  broken  ice,  floating  in  its  own  water, 
contained  in  a  bladder,  or  a  rubber  or  oil-silk  bag  of  ample  size,  is  placed 
upon  the  testicle  and  cushion.  Ice  is  useful  in  intense  neuralgia  of  the 
testicle;  harmful,  I  believe,  in  most  inflammatory  conditions. 

Numerous  internal  remedies  have  been  at  various  times  advocated  in 
the  treatment  of  epididymitis.  None  of  them  have  held  place.  The  con- 
tinued nauseant  influence  of  frequently  repeated  small  doses  of  tartar 
emetic  has  proved  of  no  value  in  my  hands.  Pulsatilla  has  been  loudly 
vaunted  of  late,  splendid  effects  being  stoutly  claimed  for  it  in  doses 
of  one-tenth  of  a  minim  often  repeated,  up  to  one  drop  three  times  a 
day.  It  has  failed  in  my  hands,  employed  in  both  ways,  either  to  check 
the  pain  or  modify  the  course  of  the  malady.  I  think  well  of  correcting 
the  strong  tendency  to  constipation,  which  always  exists  in  the  disease, 
by  the  daily  use  of  gentle  laxatives;  and  on  the  few  occasions  where  the 
pains  demand  it,  I  see  no  objection  to  the  administration  of  a  small  amount 
of  codeia  or  other  gentle  anodyne.  Beyond  this  I  cannot  recognize  any 
value  in  internal  medication. 

As  for  the  local  heroic  measures,  but  three  require  mention:  bleeding, 
puncture  of  the  tunica  vaginalis,  and  puncture  of  the  tunica  albuginea. 

Leeches  upon  the  scrotum  do  not  afford  any  considerable  relief,  accord- 
ing to  my  experience,  and  are  attended  by  obvious  disadvantages.  Where 
the  testicle  seems  to  be  strangulated  by  the  intensity  of  the  inflammation. 
a  large  number  of  leeches — ten  to  twenty — placed  over  the  upper  part  of 
the  scrotum  and  along  the  course  of  the  cord,  will  sometimes  afford  relief 
from  the  immediate  and  excruciating  pain;  but  puncture  of  the  tunica 
vaginalis,  or  of  the  albuginea,  will  afford  similar  relief  at  a  less  cost  of 
blood,  and  consequently  of  vitality. 

Puncture  of  the  tunica  vaginalis. — In  all  acute  cases  of  epididy- 
mitis there  is  more  or  less  effusion  of  serum  into  the  cavity  of  the  tunica 
vaginalis,  making  an  acute  hydrocele,  the  size  of  which  is  sometimes  con- 
siderable, generally  unimportant.  When  the  tension  within  the  testicle 
is  great,  and  the  effusion  considerable,  relief  may  sometimes  be  promptly 
afforded  the  patient  by  resorting  to  puncture  of  the  tunica  vaginalis.  A 
number  of  punctures  may  be  made  subcutaneously  with  a  fine,  sharp- 
pointed  knife,  so  that  the  fluid  may  escape  into  the  meshes  of  the  connec- 
tive tissue  of  the  scrotum,  or  the  serum  may  be  drawn  off  by  the  modern 
process  of  puncture  and  pneumatic  aspiration.  After  aspiration  the  cav- 
ity may  refill,  but  often  the  acuteness  of  the  pain  subsides  after  a  single 
puncture,  and  the  subsequent  collection  of  fluid  may  be  disregarded. 
Wrhen  the  tunic  is  not  distended,  its  puncture  does  not  afford  relief — as 
might  be  inferred. 

This  operation  is  entirely  devoid  of  any  risk  or  danger,  and  is  justifi- 
able under  all  circumstances  of  distention  of  the  tunica  vaginalis  in  con- 
nection with  acute  inflammatory  disease. 

Puncture  of  the  tunica  albuginea. — In  connection  with  epididy- 
mitis, the  secreting  structures  of  the  testicle  within  the  tunica  albuginea 
may  become  congested  and  distended  to  such  an  extent  as  to  produce  the 
intolerable  pain  of  acute  orchitis,  a  pain  felt  intensely  in  the  testicle  and 
radiating  thence  up  the  cord,  along  the  groin,  and  into  the  small  of  the 
back.  This  pain  may  often  be  relieved  at  once  by  a  single  subcutaneous 


COMPLICATIONS    OF    GONOREH(EA   IN   THE    MALE.  285 

section  of  the  tense  tunica  albuginea  to  the  extent  of  about  one-third  of 
an  inch,  or  even  less.  The  operation  is  a  simple  one.  A  sharp-pointed 
tenotome  is  introduced  obliquely  under  the  skin  of  the  scrotum,  and  the 
tunica  vaginalis  entered;  then  the  blade  is  made  to  advance  flatwise  with- 
in the  cavity  of  the  tunica  vaginalis  for  a  short  distance,  after  which  it  is 
turned  so  as  to  present  its  cutting  edge  to  the  tense  tunica  albuginea,  the 
testicle  being  steadied  by  the  operator's  free  hand.  Finally,  by  a  deliber- 
ate puncture  upward  followed  by  a  slight  incision  on  withdrawing  the 
knife,  the  incision  to  lie  at  about  the  centre  of  the  forward  part  of  the 
tunica  albuginea,  a  slight  cut  is  made  in  the  tense  tunic,  and  the  little 
operation  concluded. 

It  is  doubtful  whether  any  harm  can  follow  this  surgical  manoeuvre. 
In  a  recent  spirited  contest  upon  the  subject,  between  the  English  sur- 
geons, it  was  claimed,  on  the  one  hand,  that  this  method  of  cure  was  won- 
derfully rapid  and  absolutely  harmless  ;  while,  on  the  other  hand,  it  was 
maintained  that  the  damage  inflicted  upon  the  testicle  sometimes  caused 
its  ultimate  atrophy,  and  that  the  incision  did  not  always  either  cure 
the  pain  or  shorten  the  natural  duration  of  the  malady. 

It  is  hard  to  conceive  how  such  a  puncture  as  has  been  described  can 
really  injure  a  testicle,  and  it  seems  probable  that  those  cases  in  which 
atrophy  of  the  testicle  followed  puncture  were  instances  of  true  orchitis, 
which,  as  is  well  known,  frequently  goes  on  to  atrophy  of  the  testicle 
when  no  puncture  at  all  has  been  resorted  to.  Still,  in  face  of  the  possi- 
bility of  any  ultimate  blame  attaching  to  the  surgeon,  in  case  of  any  dam- 
age to  the  testicle,  if  puncture  has  been  employed,  it  is  well  to  resort  to 
this  procedure  only  after  mature  consideration,  and  after  ordinary  means 
of  stilling  the  pain  have  failed. 

Multiple  minute  punctures  of  the  tunica  albuginea,  made  with  a  large 
surgical  needle  or  the  point  of  a  fine,  straight  bistoury,  answer  often  as 
well  as  section  of  the  tense  membrane,  and  are  probably  attended  by  less 
risk  of  doing  harm. 

The  sheet-anchor  of  treatment  in  epididymitis,  however,  is  position  of 
the  testicle,  and,  next  to  this,  the  local  use  of  hot  fomentations  of  the  nar- 
cotic sort.  Belladonna  and  opium  in  different  forms,  as  hot  decoctions 
and  infusions,  have  been  employed  largely,  but  they  are  not  devoid  of 
danger,  and  possess  little  advantage  over  tobacco.  Tobacco  is  undoubt- 
edly a  filthy  substance,  but,  with  care,  it  may  be  so  managed  that  the  pa- 
tient is  little,  if  at  all,  soiled  by  it.  As  to  danger,  there  is  practically 
none.  Thin-skinned  persons,  who  have  never  smoked,  may  absorb 
enough  of  the  poison  to  become  faint,  pale,  nauseated,  and  dreadfully 
depressed  ;  but,  if  they  are  informed  of  the  possibility  of  these  occurrences 
beforehand,  and  remove  the  tobacco  when  the  objectionable  symptoms  first 
begin  to  appear,  the  inconvenience  soon  passes  off,  and  there  is  no  possible 
danger,  either  to  life  or  to  subsequent  health.  Excoriations  oflarge  size  upon 
the  skin  of  the  scrotum  contraindicate  the  use  of  any  narcotic  or  anodyne 
in  the  poultices,  which  must  then  be  composed  of  some  simple  material. 

To  make  a  tobacco  poultice,  which  shall  be  at  once  efficient  and  clean, 
the  following  course  may  be  followed  :  one  ounce  (a  paper,  as  ordinarily 
sold  for  chewing)  of  fine-cut  tobacco  is  to  be  finely  shredded  into  a  tin  or 
earthen  vessel,  containing  from  eight  to  ten  ounces  of  boiling  water. 
Into  this  is  put  a  tablespoonful  of  glycerine  or  of  sweet  oil,  and  into  the 
whole,  while  being  rapidly  stirred,  is  mixed  a  powder  of  equal  parts  of 
ground  elm-bark  and  ground  flaxseed,  in  sufficient  quantity  to  bring  the 
whole  mass  to  the  proper  consistence  for  a  soft  poultice. 


286  THE    VENEREAL   DISEASES. 

A  square  piece  of  oil-silk,  or  of  thin  rubber-sheeting,  two  or  three 
times  the  size  of  the  proposed  poultice,  and  containing  a  hole  at  a  suita- 
ble place,  through  which  the  penis  is  to  protrude,  is  now  to  be  laid  upon 
a  flat  surface.  Upon  this  a  doubled  piece  of  cotton  cloth,  considerably 
larger  than  the  proposed  poultice,  is  to  be  placed.  Upon  this  cotton  cloth 
the  tobacco  mixture  is  poured,  so  as  to  make  a  poultice  not  less  than  one- 
quarter  nor  more  than  half  an  inch  thick.  The  mass  should  be  about  as 
consistent  as  mush,  and  the  liquid  parts  not  in  such  excess  as  to  be  visi- 
ble. Upon  the  top  of  this  mass,  after  it  has  been  rapidly  smoothed  down 
and  squared  off,  should  be  placed  a  single  thickness  of  some  gauzy  mate- 
rial, a  little  larger  in  all  directions  than  the  tobacco  mass,  and,  finally,  the 
four  edges  of  the  doubled  cotton  cloth  should  be  turned  in  twice  upon 
themselves,  in  such  a  way  as  to  enclose  the  poultice  and  the  gauze  upon 
it  all  around,  in  a  frame,  as  it  were.  The  attachment  of  a  few  points  by 
needle  and  thread  complete  the  poultice. 

The  poultice  when  made  should  be  perfectly  moist,  soft,  and  smooth, 
but  should  never  drip.  It  should  be  large  enough  to  cover  the  entire  tes- 
ticle— indeed,  the  whole  scrotum.  Both  testicles  may  be  taken  in  with 
advantage.  The  poultice  must  be  applied  as  hot  as  it  can  be  borne,  with 
the  rubber  cloth  or  oiled  skin  outside  of  it,  the  whole  to  be  sustained  by 
the  handkerchief -sling,  described  on  page  283. 

Such  a  poultice,  so  made  and  applied,  will  keep  hot  and  moist  for  a  long 
time,  and  in  the  hands  of  a  careful  person  is  not  at  all  dirty.  If  a  little 
moisture  should  drip  away,  it  can  be  easily  caught  in  a  couple  of  folded 
towels  or  a  sheet  beneath  the  buttocks.  Two  such  poultices  in  the  twenty- 
four  hours  are  generally  sufficient.  A  tobacco  poultice  may  be  sprinkled 
with  powdered  opium  or  with  laudanum,  or  mixed  with  oleate  of  morphia,  on 
the  start,  if  an  extra  amount  of  local  stupefying  influence  over  the  pain  is 
desired. 

I  think  it  well  in  all  cases  bad  enough  to  confine  the  patient  to  bed, 
that  such  a  poultice  as  the  one  above  described  should  be  applied  at  once 
as  soon  as  the  testicle  is  suspended.  It  often  succeeds  in  stupefying  the 
testicle  within  a  few  hours  and  entirely  overcoming  the  pain.  In  all  very 
acute  or  intense  cases,  however,  this  effect  cannot  be  expected  before  the 
lapse  of  two  or  three  days,  possibly  longer. 

The  vast  majority  of  cases  of  epididymitis  call  for  no  further  treat- 
ment than  the  simple  means  already  enumerated:  mild  laxatives,  an  ele- 
vated position  of  the  testicle  with  the  patient  upon  his  back,  and  a  well- 
made  tobacco  poultice.  Under  these  means  the  acute  symptoms  pass  off 
in  a  period  varying  from  a  few  hours  in  mild  cases,  to  a  few  days,  all  pain 
disappearing  at  the  very  outside  in  two  weeks,  in  the  worst  cases.  Generally 
the  patient  who  lies  down  at  once,  even  with  a  very  severe  first  attack  of 
the  disease  (which  is  the  worst  he  can  have),  may  be  promised  that  he  will  be 
out  and  attending  to  his  business  in  ten  days,  and  this  period  under  good 
management  may  often  be  shortened  to  a  week,  while  cases  which  last 
only  from  twenty-four  hours  to  three  days  are  by  no  means  uncommon. 

When  the  acute  symptoms  are  over,  however,  the  patient  is  not  well. 
The  pain  usually  subsides  entirely  in  from  one  to  three,  or  possibly  five  or 
six  days;  but,  long  after  the  patient  ceases  to  feel  pain,  any  handling  of 
the  still  swollen  organ  makes  him  wince,  and  an  attempt  to  remain  long 
in  the  erect  position  brings  on  acute  pain.  Therefore,  if  the  patient 
wishes  to  avoid  relapse,  he  must  not  presume  to  go  about  his  business  un- 
til he  can  stand  with  the  tesicle  unsupported  for  at  least  fifteen  minutes 
without  experiencing  any  pain.  When  he  can  do  this,  he  may  go  with 


COMPLICATIONS    OF    GONORRHCEA   IN   THE   MALE.  287 

his  testicle  well  supported  in  a  snug  suspensory,  inside  of  which  is  a  piece 
of  thin  rubber  and  a  piece  of  prepared  lint,  smeared,  perhaps  more  for 
form's  sake  than  anything  else,  with  some  indifferent  ointment. 


STRAPPING. 

« 

Should  a  patient  find  it  necessary  to  leave  his  bed  before  completing 
his  week  or  ten  days,  and  not  be  able  to  wait  until  he  can  stand  erect  for 
fifteen  minutes  without  pain,  he  may  do  so  by  the  aid  of  strapping.  Just  as 
soon  as  the  acute  symptoms  are  fairly  on  the  decline  and  the  testicle  can 
be  handled,  even  although  it  be  with  pain,  the  patient  may  get  up  and 
go  about  with  safety,  so  far  as  relapse  is  concerned,  if  the  testicle  be  prop- 
erly strapped.  Strapping  should  be  first  done  at  night,  and  the  first 
straps  should  be  put  on  with  great  gentleness  and  not  too  tightly.  The 
patient  must  be  directed  to  stay  in  bed  all  night,  and  to  remove  the  straps 
or  to  cut  them  down  the  front,  if  the  testicle  be  not  quite  comfortable  in 
half  an  hour  after  the  straps  have  been  applied. 

An  effectual  method  of  applying  straps  is  the  following:  a  number  of 
strips  are  cut  from  a  roll  of  fresh  adhesive  plaster,  ranging  about  ten 
inches  long  by  three-quarters  of  an  inch  wide.  If  the  plaster  be  not  very 
fresh,  an  assistant  is  necessary  to  warm  the  strips  of  plaster  one  after  an- 
other, and  hand  them  to  the  operator.  The  patient  sits  upon  the  edge  of 
the  bed,  with  his  thighs  stretched  wide  apart.  The  operator,  upon  a  low 
chair,  sits  directly  in  front  of  him,  seizes  the  enlarged  testicle  gently  with 
his  left  hand  above  the  globus  major,  and,  by  a  motion  at  once  rotary  and 
constricting,  under  gentle  traction  he  pulls  the  testicle  down  until  he  can 
easily  encircle  the  cord  above  with  his  thumb  and  index  finger. 

The  sound  testicle  meantime  slips  up  upon  the  opposite  side,  and  the 
whole  scrotum  is  pinched  in  about  the  neck  of  the  swollen  testicle,  and 
held  there  for  a  moment  with  the  finger  and  thumb  of  the  operator's  left 
hand,  until  the  parts  become  used  to  the  traction  and  the  tension.  Now  a 
piece  of  prepared  lint,  previously  cut  long  enough  to  surround  the  top  of 
the  testicle  and  about  one  and  one-half  inch  broad,  is  placed  under  the  in- 
dex finger  and  thumb  posteriorly  and  brought  forward  so  as  to  surround 
the  neck  of  the  testicle,  while  its  free  ends  cross  in  front  and  lie  below 
upon  the  body  of  the  tumor. 

The  object  of  this  lint  is  to  prevent  the  cutting  to  which  the  tight  top 
strap  subjects  the  tender  integument  of  the  scrotum.  After  it  has  been 
satisfactorily  adjusted,  the  first  adhesive  strap  is  to  be  placed.  This  is 
done  by  holding  the  two  free  ends  of  the  lint  with  the  underlying  scrotum 
tightly  about  the  neck  of  the  tumor,  while  the  centre  of  the  adhesive  strip 
is  placed  posteriorly  upon  the  centre  of  the  strip  of  lint.  One  end  of  the 
adhesive  strip  is  now  brought  around,  following  the  centre  of  the  strip  of 
lint,  and  attached  to  the  integument  of  the  scrotum  beyond  the  lint. 
Finally,  the  other  end  of  the  adhesive  strip,  also  following  the  centre  of  its 
half  of  the  lint  strip,  is  brought  around  under  considerable  pressure  and 
attached  either  upon  the  half  of  the  adhesive  strip  already  placed,  or  cross- 
ing the  latter  upon  the  integument  over  the  tumor  below. 

Upon  the  successful  laying  of  the  top  strap  depends  the  success  or  the 
failure  of  the  whole  strapping.  If  it  does  not  lie  smoothly  and  retain  the 
testicle  tightly,  it  is  well  to  remove  it  and  put  on  another.  How  tight  it 
must  be  is  of  course  a  matter  of  judgment;  but  the  tendency  certainly  is 
to  make  it  too  loose,  and  it  always  seems  to  be  tighter  than  it  is  on  account 


288  THE   VENEREAL   DISEASES. 

of  the  shining1,  tense,  purple  look  of  the  scrotum  beneath,  if  it  be  allowed 
to  remain  a  moment,  due  to  the  arrest  of  the  return  circulation  in  the 
veins. 

To  place  the  other  straps  is  now  an  easy  matter.  Each  one  is  to  be 
started  posteriorly,  and  to  overlap  the  one  above  by  half  or  even  two-thirds 
its  breadth,  and  each  half  of  each  strap  is  to  be  brought  around  under  con- 
siderable tension,  preserving  its  relation  to  the  upper  strap,  attached,  and 
cut  off  at  a  suitable  length. 

Going  down  the  testicle,  the  straps  are  made  to  lie  more  and  more  in 
a  circular  direction,  until  finally  a  strap  is  placed  which  leaves  the  egg- 
shaped  end  of  the  livid  scrotum  projecting  beneath  it,  not  covered,  but  yet 
incapable  of  receiving  any  more  circular  straps.  If  any  of  the  circular 
straps  now  prove  so  tight  as  to  push  the  testicle  up  through  the  constrict- 
ing ring  formed  by  the  top  strap,  the  dressing  is  worthless,  and  must  be 
reapplied.  If,  however,  the  testicle  is  tightly  held,  its  remaining  livid  ex- 
tremity may  be  bound  in  by  a  number  of  short,  broad  straps  very  tightly 
applied  from  behind  forward,  and  laterally,  until  the  whole  of  the  testicle 
has  been  covered  in. 

These  last  straps  are  quite  important.  They  cannot  be  put  on  too 
tightly,  and,  to  place  them  at  all  properly,  the  testicle  has  to  be  squeezed 
enough  to  give  the  patient  a  great  deal  of  pain.  Outside  of  these  final 
straps  another  circular  one  may  or  may  not  be  placed,  according  to  taste, 
and  the  strapping  is  complete. 

When  a  testicle,  after  acute  inflammation,  is  snugly  strapped  for  the 
first  time,  it  is  apt  to  throb  and  grow  painful  for  a  time.  If,  at  the  end 
of  half  an  hour,  the  patient  lying  down,  the  pain  has  gone  or  is  subsiding, 
the  strapping  is  efficient  and  may  be  left  in  place.  Long  before  morning 
the  testicle  will  have  become  perfectly  comfortable,  and  the  patient  may 
go  around  at  will  through  the  day,  wearing  an  ordinary  suspensory  band- 
age or  continuing  his  handkerchief-sling,  without  fear  of  relapse  and  without 
feeling  pain.  If,  on  the  contrary,  half  an  hour  after  the  straps  have  been 
applied,  the  pain  is  on  the  increase,  the  straps  must  be  removed  or  cut  down 
the  front,  or  the  pain  will  continue,  will  grow  insufferable,  and  probably 
prolong  the  whole  attack  of  epididymitis  many  days  by  reason  of  a  fresh 
onset  of  inflammation.  In  any  case,  if  the  pain  be  intense  after  half  an 
hour,  the  straps  have  been  improperly  applied,  and  have  done  harm  instead 
of  good. 

The  first  strapping,  if  a  good  one,  should  last  forty-eight  hours.  It 
may  be  most  conveniently  removed  by  the  patient  in  a  hot  bath.  After 
the  straps  become  thoroughly  soaked  in  the  water,  they  come  off  readily, 
and  then  a  little  soap  and  water  does  all  that  need  be  done  toward  remov- 
ing the  adherent  plaster. 

New  straps  should  be  applied  at  once  as  tightly  as  the  first,  or  even 
more  tightly,  to  overcome  the  oedema  which  is  sure  to  be  found  at  the  bot- 
tom of  the  scrotum,  replacing  within  the  strapping  whatever  bulk  has 
been  lost  by  the  testicle.  These  second  straps  may  remain  on  for  three 
days,  when,  usually,  none  further  will  be  needed. 


CHRONIC    EPIDIDYMITIS. 

In  successive  gonorrhoeas,  or  in  connection  with  stricture  or  other 
urethral  inflammatory  affection,  partial  epididymitis  often  comes  on,  es- 
pecially in  a  testicle  which  has  once  been  the  seat  of  acute  inflammation. 


COMPLICATIONS    OF    GONORRIICEA    IN    THE    MALE.  289 

In  these  attacks  the  symptoms  are  usually  quite  moderate.  The  hard 
lump  at  the  tail  (usually),  or  in  the  head  of  the  epididymis,  sufficiently 
discloses  the  nature  of  the  disorder  and  the  cause  of  the  pain. 

These  cases  are  generally  easy  to  manage.  A  few  days'  rest,  even 
without  poulticing,  often  makes  the  pain  so  tolerable  that  a  little  warm 
swathing  in  a  suspensory  bandage  allows  the  patient  to  get  about. 

Mercurial  ointments  and  iodine  are  of  little  value  in  these  states.  The 
main  reliance  is  to  be  placed  upon  curing  the  cause  and  getting  the  ure- 
thra into  good  condition.  Instrumentation  within  the  urethra,  and  injec- 
tions, are  to  be  avoided  until  tenderness  has  left  the  testicle.  As  good  a 
local  application  as  any  in  these  cases  is  the  oleate  of  morphia  rubbed  up 
with  fresh  stramonium  ointment,  one  part  to  two.-  It  makes  a  soft,  oily 
mass,  which  may  be  applied  on  lint  inside  of  the  thin  rubber  which  the 
suspensory  bandage  surrounds. 

The  treatment  of  the  sterility  following  epididymitis  has  already  been 
considered. 

The  question  of  abscess  following  localized  epididymitis,  and  of  pseudo- 
tubercular  disease  of  the  testicle,  is  out  of  place  in  a  work  of  this  character. 

19 


CHAPTER  IV. 
STRICTURE  OF  LARGE  CALIBRE. 

Stricture  of  the  Male  Urethra. — Spasmodic  Stricture. — Examples  of  this  Form  of  Stric- 
ture.— Stricture  of  Large  Calibre  :  Symptoms,  Diagnosis,  Treatment. — Resiliary 
Strictures  of  Large  Calibre. — Internal  Urethrotomy  in  the  Pendulous  Urethra,  the 
Limit  of  the  Cut,  the  Result,  and  the  After-treatment. 

A  VERY  common  result  of  gonorrhoea  in  the  male  is  the  formation  of 
stricture  of  the  urethra.  Stricture  may  be  due  to  many  other  causes, 
such  as  trumatic  violence  of  any  sort,  mechanical  or  chemical,  especially 
any  kind  of  bruising  of  the  canal  transversely;  or  to  congenital  imperfec- 
tion of  the  urethra,  particularly  common  at  the  meatus;  or  to  spasmodic 
action  of  the  muscles  of  the  deep  urethra,  sometimes  reflex;  yet  all  these 
causes  combined  only  yield  a  small  proportion  of  the  cases  of  real  stricture — 
stricture  producing  symptoms  as  encountered  in  ordinary  practice.  Many 
cases  of  gonorrhoea  get  well  and  leave  the  urethra  sound,  even  although 
the  urethral  inflammation  has  been  intense  and  prolonged.  On  the  other 
hand,  many  cases  of  mild  urethritis,  which  are  not  due  to  gonorrhoeal  poi- 
soning and  have  never  run  high  in  the  suppurative  stage,  prolong  them- 
selves indefinitely  in  the  shape  of  a  gleet,  and  exploration  of  the  urethra 
demonstrates  that  there  is  a  tight  place  in  the  canal  yielding  a  tinge  of 
blood  to  the  exploring  instrument,  manifestly  excoriated  upon  its  surface, 
and  clearly  the  lesion  whence  proceeds  the  oozing  which  constitutes  the 
gleet. 

The  question  of  spasmodic  stricture  is  so  interwoven  with  that  of 
organic  stricture,  that  neither  of  them  can  well  be  considered  apart  from 
the  other;  and  although,  accurately  speaking,  stricture  of  the  urethra 
is  no  more  a  venereal  disease  than  uraemia  is  scarlet  fever,  yet  it  is  so 
closely  related  in  many  ways  to  gonorrhoea  that  its  description  naturally 
falls  into  place  here,  and  the  various  forms  of  stricture  call  equally  for  a 
certain  amount  of  detail. 

I  shall  describe  the  three  forms  of  stricture  inversely  as  to  their  im- 
portance, taking  up  first  the  spasmodic  stricture,  next  the  stricture  of 
large  calibre,  and,  finally,  the  stricture  of  small  calibre. 


SPASMODIC    STRICTURE    OF   THE    URETHRA. 

The  existence  of  spasmodic  stricture  of  the  urethra  has  been  doubted, 
but  it  plainly  is  a  reality,  as  may  be  easily  demonstrated.  It  is  indeed 
the  least  venereal  of  all  strictures,  and  may  depend  upon  a  multitude  of 
causes,  general  as  well  as  local,  moral  as  well  as  physical.  Moreover,  it 
may  complicate  either  of  the  other  forms  of  stricture  and  give  to  them  an 
importance  which  they  would  not  otherwise  possess.  In  this  way  spas- 
modic stricture  earns  for  itself  a  right  to  respectful  consideration;  its  ex- 
istence cannot  be  ignored. 


STRICTURE    OF   LARGE   CALIBRE.  291 

Spasmodic  stricture  is  generally  capable  of  very  easy  demonstration. 
A  personal  case  will  well  illustrate  this. 

A  young  man,  under  twenty  years  of  age,  and  perfectly  healthy  so 
far  as  urethral  or  antecedent  venereal  disease  of  any  kind  was  concerned, 
finding  some  pediculi  upon  his  pubis,  was  kindly  supplied  with  a  lotion  by 
an  obliging  friend,  with  which  to  kill  them.  This  he  applied  faithfully  in 
the  morning.  The  lotion,  which  proved  to  be  simple  tincture  of  staves- 
acre,  proved  quite  irritating,  and  presently  occasioned  much  tingling  and 
burning  of  the  skin  where  it  had  been  applied,  and  brought  on  a  desire 
to  urinate;  but  the  patient  to  his  surprise  found  that  he  could  not  void  a 
drop  of  urine,  the  bladder  being  only  slightly  distended. 

He  continued  up  and  about  all  day,  making  repeated  but  absolutely 
futile  efforts  to  empty  his  bladder,  and  finally  was  brought  to  my  office 
for  relief  late  in  the  afternoon.  I  at  once  passed  a  full-sized  olivary 
soft  catheter  into  the  bladder,  encountering  no  obstacle,  and  a  clear, 
bright  stream  of  urine  gushed  out  in  torrents  through  the  instrument  to 
the  amount  of  more  than  a  pint. 

The  patient  passed  water  voluntarily  in  the  evening  before  retiring, 
and  has  had  no  further  trouble. 

This  case  was  certainly  one  of  spasmodic  stricture  of  the  muscles  of 
the  deep  urethra,  due  to  irritation  reflected  from  the  skin.  There  was  no 
present  or  past  malady  of  the  bladder  or  urethra,  and  has  been  none 
since.  Efforts  were  made  in  vain  by  the  patient  to  empty  his  bladder 
during  all  stages  of  fulness.  There  was  not  a  particle  of  atony  in  the 
•case,  for,  as  soon  as  the  urine  found  a  hole  from  which  to  escape,  it 
gushed  forth  under  the  powerful  contraction  of  the  detrusor,  and  did  hot 
dribble  away  sluggishly  from  the  end  of  the  catheter,  as  it  is  wont  to  do 
in  cases  of  atony,  unless  aided  by  the  efforts  of  the  abdominal  muscles. 
The  stream  in  this  case  continued  with  equal  force  and  vigor  up  to  the 
last  few  drops.  Here  then  is  a  case  of  pure  reflex  spasm  of  the  urethra. 

In  the  autumn  of  1877  an  old  man  applied  to  me  for  relief  on  account 
of  frequent,  painful,  and  imperfect  urination  in  a  small  stream,  his  symp- 
toms being  particularly  troublesome  at  night.  He  squeezed  out  a  few 
drops  of  urine  in  my  presence,  in  a  small  stream  and  with  great  pain. 
The  urine  was  clear  and  sparkling,  of  normal  reaction. 

The  patient  was  very  thin,  and  percussion  and  palpation  over  his  abdo- 
men quickly  made  it  apparent  that  the  bladder  was  fully  distended.  The 
natural  inference  in  the  case  of  this  old  man  was  that  he  was  suffering 
from  prostatic  overgrowth  and  atony.  I  told  him  that  I  should  endeavor 
to  introduce  a  catheter,  and  should  draw  off  a  portion  only  of  the  con- 
tents of  his  bladder.  I  introduced  a  soft  rubber  English  catheter  of  full 
size.  It  halted  sensibly  for  a  moment  at  the  membranous  urethra,  and 
then  slipped  rapidly  into  the  bladder;  but  before  its  eye  had  reached  the 
cavity  of  the  bladder,  urine  began  to  pour  tumultuously  out,  both  through 
the  catheter  and  along  the  outside  of  it.  So  violently  did  the  urine  flov,-, 
that  it  was  with  difficulty  the  catheter  could  be  retained  in  the  bladder 
to  allow  part  of  the  flow  to  escape  through  it,  and  even  this  was  finally 
abandoned,  and  the  rushing  stream  of  urine  swept  the  catheter  out  of  the 
urethra,  and  followed  in  a  continuous  stream  of  full  size  and  force  until 
every  drop  had  escaped  from  the  bladder.  Of  this  I  satisfied  myself  by 
reintroducing  the  instrument.  The  urine  was  of  the  best  quality,  per- 
fectly bright  and  clear.  Surely  there  was  no  valve  here,  no  prostatio 
lobule,  no  atony — nothing  but  spasm  of  the  deep  urethral  muscles. 

The  old  man's  urethra  was  perfectly  healthy  as  to  any  present  or  past 


292  THE    VENEREAL    DISEASES. 

inflammatory  disturbance,  and  in  seeking  a  cause  for  the  retention,  I 
found  that  his  rectum  was  in  trouble.  He  stated  that  he  had  had  haemor- 
rhoids for  several  years,  but  he  begged  me  not  to  examine  them,  saying 
that  he  was  using  an  ointment  as  a  suppository  which  gave  him  relief, 
and  that  he  did  not  desire  to  do  anything  else,  and  would  not  be  exam- 
ined. I  could  not  overcome  his  scruples,  and  had  to  wait  for  develop- 
ments. 

Meantime  the  old  man  got  a  soft  catheter,  and  used  it  when  he  had 
retention.  It  was  only  necessary  to  start  the  urine  by  introducing  the 
catheter  up  to  the  neck  of  the  bladder,  after  which,  on  each  occasion,  the 
urethra  performed  its  function  perfectly.  For  many  days  at  a  time  he 
would  pass  his  water  as  well  as  any  one,  and  then  suddenly,  without 
obvious  cause,  retention  would  again  overtake  him,  and  perhaps  persist 
for  a  day  or  more — or  pass  off,  if  the  catheter  was  promptly  used. 

I  soon  got  access  to  this  patient's  rectum,  and  found  it  to  be  the  seat 
of  epithelial  cancer  just  beginning  to  ulcerate.  The  prostate  was  not 
enlarged.  Here  then  was  an  explanation  of  the  spasmodic  stricture. 

The  case  was  not  a  fit  one  for  operation  upon  the  rectum.  I  watched 
the  patient  for  about  a  year,  when  he  died  from  progress  of  his  cancer, 
which  involved  the  sphincter  and  the  neighborhood  of  the  anus,  but  never 
touched  the  bladder  or  urethra.  Urinary  symptoms  continued  in  an  in- 
termittent way  until  the  end. 

In  1868,  Dr.  Van  Buren  snipped  off  one  small  tab  of  skin — the  result 
of  an  external  hasmorrhoid — not  at  the  time  at  all  inflamed,  but  simply 
annoying  by  its  presence.  The  patient  was  an  old  gentleman  in  the  best 
of  surroundings.  He  took  no  ether  for  the  little  operation,  and  the 
sphincter  was  not  stretched.  His  urinary  organs  were  in  perfect  condi- 
tion. For  five  days  after  this  trifling  operation  he  could  not  urinate, 
and  a  soft  catheter  had  to  be  introduced  three  or  four  times  a  day.  After 
this  he  got  well,  and  did  not  use  a  catheter  again  until  his  death,  which 
occurred  some  years  later. 

In  1876,  I  stretched  the  sphincter,  under  ether,  and  tied  off  some 
internal  haemorrhoids  in  a  man  under  middle  age.  From  the  moment  of 
the  operation  until  the  eleventh  day,  not  one  drop  of  urine  could  this 
patient  void  spontaneously.  A  catheter  was  in  constant  demand.  His 
urethra  was  sound,  and  he  became  and  continued  well,  after  the  soreness 
left  his  rectum. 

Dr.  Emmet  has  seen  a  case  where  necrosis  of  the  coccyx  produced 
spasmodic  stricture  of  the  urethra;  and  Verneuil  a  similar  condition,  due 
to  abscess  in  one  of  the  seminal  vesicles.  I  have  two  personal  cases 
where  stricture  of  this  sort  was  due  to  reflected  irritation  from  a  chroni- 
cally inflamed  seminal  vesicle,  and  notes  of  a  number  of  other  cases  due 
to  the  most  varied  causes. 

Tuffnell's  case  is  well  known,  where  a  patient  had  a  stricture  deemed 
impassable  (doubtless  because  fine  bougies  only  were  used  in  attempts 
to  pass  it).  This  patient  suffered  so  much,  that  a  day  was  appointed 
upon  which  perineal  section  should  be  performed;  but,  before  the  date  ar- 
rived, he  passed  some  links  of  tape-worm,  unsuspected  before,  and,  as  a 
part  of  the  preparation  for  his  operation,  a  medicine  was  given  to  dis- 
lodge the  worm.  This  proved  successful.  The  worm  was  passed,  and 
with  it  the  impassable  stricture  disappeared,  and  the  patient  urinated 
freely  at  will. 

It  has  occurred  several  times,  in  my  experience,  for  a  surgeon  to 
make  a  diagnosis  of  tight  stricture  in  a  given  case,  and  to  find  his  filiform 


STKICTUEE    OF   LARGE    CALIBRE.  293 

bougie — which  he  has  passed  with  difficulty — grasped,  as  he  attempted  to 
withdraw  it,  when  there  has  been  nothing  more  in  the  case  than  spasmo- 
dic stricture  of  the  deep  urethra,  as  proved  by  the  fact  that  a  well- 
warmed,  large,  blunt  steel  sound,  held  gently  against  the  face  of  the 
obstacle,  has,  after  a  short  delay,  slipped,  by  its  own  weight,  smoothly 
into  the  bladder. 

The  medical  journals,  and  surgical  books  and  theses  of  the  past  as 
well  as  the  present  day,  contain  plentiful  examples  of  spasmodic  stric- 
ture. Dartigues,  in  his  Thesis  (Paris,  1873),  quoting  Hippocrates,  Mal- 
gaigne,  Cooper,  and  others,  as  authority,  refers  to  many  cases  of  reten- 
tion from  spasm  of  the  urethra  following  various  surgical  injuries,  such 
as  luxation  of  the  hip  forward,  amputation  of  the  thigh  (five  cases),  ab- 
lation of  the  breast,  breaking  up  of  anchylosis  of  the  knee.  The  influ- 
ence of  a  tight  meatus  upon  the  deep  urethra,  of  phymosis,  of  irritations 
in  the  kidney,  and  of  other  more  distant  lesions,  have  claimed  attention 
from  time  to  time.  Reflex  phenomena,  as  affecting  the  urinary  organs 
and  caused  by  them,  have  received  a  certain  share  of  attention.  (Civiale 
and  others  have  called  it  sympathy).  Prof.  Sands  has  collected,  from  the 
older  writers  before  the  time  of  Civiale,  a  number  of  interesting  in- 
stances of  lesions  involving  the  urinary  organs  as  cause  of  distant  trou- 
bles (Home's  case  of  sciatica,  due  to  stricture,  being  perhaps  the  most 
striking),  and  a  few  of  urinary  troubles  due  to  perinea!  irritation,  one  of 
these  being  strangury  induced  by  teething,  in  a  boy,  and  relieved  by 
cutting  the  gums.  (Hospital  Gazette,  May  3,  1879,  p.  132.)  Verneuil, 
in  France,  in  1866,  before  the  Anatomical  Society  of  Paris,  pushed  the 
spasmodic  theory  so  far  as  to  claim  that  most  strictures  were  to  be  found 
in  the  forepart  of  the  urethra,  and  not  deeper,  as  had  been  taught — many 
of  the  supposed  deep  organic  strictures  being  only  spasmodic  strictures 
due  to  irritation  in  the  forepart  of  the  canal.  Folet l  followed  his  master 
in  establishing  the  new  doctrine. 

Otis,2  in  this  country,  has  generalized,  from  his  own  experience,  laws 
still  more  positive  than  Verneuil,  claiming  that  organic  stricture  is  very 
common  forward,  and  quite  infrequently  occurs  in  the  deep  urethra, 
spasm  being  at  the  bottom  of  most  of  the  so-called  tight  organic  stric- 
tures in  this  region.  Dr.  Otis's  first  publication  on  the  subject  was  in 
1873. 

These  gentlemen  have,  however,  as  yet  failed  to  convince  a  majority 
of  the  sober-minded  men  in  the  profession,  either  by  their  cases  or  their 
arguments,  that  spasmodic  stricture  of  the  deep  urethra  is  so  common,  or 
organic  stricture  so  rare.  As  stated  by  Sebeaux,3  Verneuil's  law  is  the 
following:  all  spasmodic  strictures  due  to  irritation  of  the  urethra  are 
situated  in  the  membranous  portion  of  the  canal;  if  due  to  irritation 
above  the  vesical  neck,  on  the  other  hand,  the  stricture  lies  in  the  poste- 
rior vesical  sphincter,  which  is  composed  of  unstriped  muscular  fibre. 
Robin  and  Cadiat  state  4  it  as  their  belief  that  the  spasm  lies  always  in 
the  unstriped,  never  in  striped  muscular  fibre;  but  they  do  not  appear  to 
me  at  all  to  demonstrate  their  position.  The  fact  that  females  have  re- 

1  fitudes  sur  les  retrecissements  peniens  de  1'urethre.     Archiv.  gen.,  1867,  Vol.  I., 
p.  424. 

2  Radical  Cure  of  Stricture  of  the  Male  Urethra.     New  York,  1878. 

3  Contracture  du  col  de  la  vessie.     Paris,  1876,  p.  32. 

4  Sur  la  structure  intime  de  la  muqueuse  et  des  glandes  urotbrales  de  rhomme  et 
de  la  femme.     Journ.  d'aiiatomie  etde  la  physiologic,  1874,  p.  531. 


294  THE    VENEREAL    DISEASES. 

tention  of  urine,  apparently  due  to  spasmodic  stricture,  seems  to  justify 
the  assertions  of  Robin  and  Cadiat. 

Spasmodic  stricture  certainly  exists.  There  is  more  of  it  than  some 
of  the  best  authorities  allow,  but  far  less  of  it  than  a  few  enthusiastic 
writers  would  lead  one  to  suppose.  The  last  word  has  not  been  spoken 
upon  the  subject,  and  probably  will  not  be  until  the  unfortunate  personal 
feeling,  which  is  at  present  obvious  in  all  discussions  on  the  subject,  shall 
have  passed  away. 

Who  is  unfamiliar  with  the  effect  of  shame,  haste,  anxiety,  anger,  ner- 
vous excitability,  and  other  emotions,  in  making  it  absolutely  impossible 
for  a  perfectly  healthy  patient,  sometimes,  to  make  water  at  all  for  a  con- 
siderable time  ?  Such  retention  is  due  to  a  spasm  of  the  urethra.  The  so- 
called  inflammatory  stricture  is  usually  only  a  secondary  spasm,  induced 
by  the  irritated  state  of  the  urethra;  for  the  swelling  of  the  urethra  alone 
could  hardly  successfully  oppose  the  detrusor.  The  grasping  of  a  sound 
by  an  organic  stricture,  through  which  the  instrument  has  been  passed,  is 
due  to  spasm.  The  lack  of  co-ordination  between  the  detruscr  and  the  cut- 
off muscles,  often  leading  to  retention  in  cases  of  locomotor  ataxia  and 
partial  paraplegia  (especially  syphilitic),  acts  apparently  by  causing  spasm 
of  the  deep  urethral  muscles.  The  different  conditions  in  which  deep  or- 
ganic stricture  habitually  finds  itself — sometimes  allowing  a  reasonably 
free  stream  of  urine  to  pass,  again  so  nearly  closed  up  that  only  a  few 
drops  can  be  painfully  voided  with  great  effort — this  difference  is  undoubt- 
edly due  more  to  spasm  than  it  is  to  any  purely  inflammatory  change  in 
the  stricture  itself.  That  form  of  partial  or  complete  retention  sometimes 
seen  in  connection  with  a  very  slight  stricture  of  large  calibre,  either  in 
the  deep  or  in  the  pendulous  urethra,  is  certainly  due  to  spasm,  as  proved 
by  the  ease  with  which  many  of  these  cases  allow  the  passage  of  a  large- 
sized  steel  instrument  without  the  employment  of  any  force.  Of  this 
form  of  stricture  1  have  seen  several  instances.  Some  of  the  numerous 
cases  reported  by  Dr.  Otis  are  excellent  examples  of  spasmodic  stricture. 
In  some  of  the  cases  his  diagnosis  has  been  questioned,  but  most  of  them 
are  striking  examples  of  the  malady  in  question. 

Treatment. — The  surgeon's  tact  and  ability  are  often  largely  taxed 
to  discover  the  cause  of  deep  urethral  irritability  and  spasm.  To  be  suc- 
cessful in  his  treatment  he  must  find  the  cause;  when  that  is  removed  the 
stricture  will  get  well.  The  cause  may  lie  in  a  tight  meatus,  or  in  an  ir- 
ritable anterior  or  posterior  stricture  of  large  or  small  calibre;  but  the 
spasm  is  not,  by  any  means,  always- due  to  such  a  cause.  I  have  knowl- 
edge of  a  number  of  cases  in  which  the  urethra  has  been  extensively  cut 
in  its  forward  parts,  in  accordance  with  the  views  of  the  most  modern 
school  in  urethral  pathology  and  therapeutics,  without  the  slightest  ad- 
vantage to  the  patient,  although  the  moral  effect  of  a  surgical  operation 
is  sometimes  sufficient  to  cause  a  patient  to  declare  himself  better  during 
a  long  enough  time  for  his  case  to  get  into  print. 

Some  deaths  have  followed  the  use  of  the  dilating  urethrotome.  I  lost 
one  patient  in  March,  1873,  and  showed  the  diseased  kidneys  to  the  Path- 
ological Society  during  the  same  month.  In  this  case  a  deep  stricture 
was  divided,  and  the  same  result  would  have  followed  the  use  of  any  other 
instrument,  the  kidneys  being  at  fault.  Dr.  Sands,  in  one  of  his  contro- 
versial papers,  reports  three  fatal  cases  of  urethrotomj',  in  which  the  di- 
lating urethrotome  was  used.  Dr.  Otis,  in  his  reply  in  the  Hospital 
Gazette  of  June  28,  1879,  endeavors  to  relieve  the  instrument  from  any 
blame  in  these  cases.  But  the  citation  of  cases  is  of  no  value  in  this 


STRICTURE    OF   LARGE    CALIBRE.  295 

connection.  No  one  can  doubt  the  mechanical  excellence  of  Dr.  Otis's 
instrument;  nor  can  one  doubt  that,  where  any  cutting  operation  will  kill, 
death  will  follow  the  cut,  no  matter  by  what  instrument  the  cut  is  made. 
The  reason  why  the  operations  made  with  the  dilating  urethrotome  show 
such  a  light  mortality  is,  that  these  operations  are  performed  almost  ex- 
clusively upon  the  pendulous  urethra,  and  urethrotomy  in  this  region  is  a 
most  trivial  matter  when  compared  with  the  same  operation  performed 
upon  the  deeper  portions  of  the  canal.  Death  very  rarely  follows  ure- 
throtomy in  the  pendulous  urethra.  The  nearer  the  meatus,  the  less  the 
risk;  but  this  fact  does  not  make  promiscuous  and  unnecessary  cutting 
any  the  more  surgical. 

The  pendulous  urethra  should  be  respected  when  possible,  and  left  as 
nature  made  it.  That  it  may  generally  be  cut  with  little  or  no  risk  to  life 
by  no  means  justifies  an  operation  not  imperatively  demanded  by  the 
symptoms  in  a  given  case. 

I  have  tested  the  new  method  quite  extensively,  and  find  myself  in- 
clined, by  experience,  to  be  more  and  more  conservative,  and  to  cut  less 
and  less  within  the  urethra  anywhere  beyond  the  first  three-quarters  of 
an  inch  from  the  meatus — except  in  desperate  cases — believing  that  such 
cutting,  on  the  whole,  does  more  harm  than  good  in  a  majority  of  instan- 
ces. This  conclusion  is  a  growing  one,  and  has  been  deliberately  reached. 
It  is  based  not  only  upon  my  own  cases  which  I  have  cut,  but  also  upon 
a  considerable  number  of  patients  whom  I  have  cared  for  on  account  of  the 
same  malady,  for  which  they  had  been  unsuccessfully  cut,  in  some  cases 
a  number  of  times,  by  the  foremost  advocates  of  our  day  for  extensive 
anterior  internal  urethrotomy.  I  do  not  by  any  means  condemn  this  oper- 
ation, which  I  think  an  excellent  one  and  indispensable  to  the  cure  of  some 
cases;  but  what  I  do  feel  called  upon  to  condemn,  is  the  extensive  in- 
discriminate cutting  of  the  anterior  urethra,  now  commonly  indulged 
in,  especially  by  young  surgeons,  for  any  and  all  possible  morbid  condi- 
tions of  the  urethra,  simply  because  the  canal  is  smaller  in  some  parts 
than  it  is  in  others,  as  the  Almighty  evidently  intended  that  it  should  be. 
This  will  be  again  referred  to  at  p.  296. 

The  treatment  of  spasmodic  stricture,  then,  is  to  find  and  remove  the 
cause.  If  that  cause  seems  to  be  an  organic  stricture  of  the  urethra  any- 
where situated,  that  stricture  must  be  appropriately  dealt  with. 

The  treatment  of  organic  stricture  will  be  discussed  after  a  descrip- 
tion of  the  stricture  itself. 


STEICTUEE    OF   LABGE    CALIBRE. 

Stricture  of  large  calibre  may  be  encountered  anywhere  along  the 
urethra  from  the  meatus  up  to  the  apex  of  the  prostate.  Stricture  of  the 
prostate  does  not  exist.  One  or  two  instances  of  it  only  have  been  en- 
countered, or  at  least  recorded.  Obstruction,  both  to  the  passage  of  urine 
and  to  the  introduction  of  instruments,  undoubtedly  occurs  in  the  pros- 
tate; but  such  obstruction  is  due  to  hypertrophic,  congestive,  or  degen- 
erative causes,  involving  the  prostatic  body,  and  not  to  any  stricture  situ- 
ated in  the  sinus  itself. 

The  distinction  between  a  stricture  of  large  calibre  and  one  of  small 
calibre  is,  of  course,  an  arbitrary  one.  In  a  general  way  it  may  be  stated 
that  any  stricture,  which  may  be  safely  treated  by  dilatation  with  solid 
steel  conical  instruments,  is  a  stricture  of  large  calibre,  while  one  which 


296  THE    VENEREAL   DISEASES. 

may  not  be  so  treated  must  be  ranked  of  small  calibre.  Such  a  rule 
places  the  boundary  between  large  and  small  calibration  at  10  of  the 
American  scale,  an  instrument  five  millimetres  in  diameter  (15  French). 
Below  this  a  conical  steel  instrument  should  not,  as  a  rule,  be  employed 
in  the  urethra  for  dilating  purposes. 

Stricture  of  large  calibre  is  frequently  congenital  at  the  meatus — that 
is,  the  meatus  is  not  developed  to  the  extent  to  which  nature  intended 
that  it  should  be.  The  meatus  is  often  found  sealed  up  to  the  size  of  a 
pin-head,  livid  in  color,  conical  in  shape,  pouting,  manifestly  unnatural. 
From  this  upward  it  is  found  of  all  sizes,  sometimes  altogether  dispro- 
portionately large  as  compared  with  the  rest  of  the  canal. 

Now,  the  meatus  should  be  the  smallest  place  in  the  urethra,  just  as  the 
nozzle  of  any  hose-pipe  is  smaller  than  the  tube  itself;  and  this  is  neces- 
sary for  the  vigorous  delivery  of  a  full,  smooth  stream.  How  then  shall  one 
decide  whether  the  meatus  is  too  small  or  not  ?  Simply  by  ascertaining 
whether  there  is  any  cul-de-sac,  any  pouch  behind  either  angle  of  the  meatus, 
on  the  roof  or  on  the  floor  of  the  canal.  If  a  probe  passed  into  the  orifice 
can  make  such  a  pouch,  then  the  meatus  is  too  small.  This  smallness  is 
generally  a  congenital  deformity  and  not  a  pathological  condition,  and 
its  existence  never  calls  for  any  interference  on  the  part  of  the  surgeon, 
unless  it  be  presumed  to  be  the  probable  cause  of  symptoms,  or  unless  it 
interferes  by  its  smallness  of  size  with  the  proper  treatment  by  instru- 
ments of  morbid  conditions  of  the  urethra  more  deeply  seated,  or  of  the 
bladder.  Interference  with  the  meatus  for  any  other  cause  than  these  is 
meddlesome  and  unsurgical. 

The  same  general  line  of  argument  applies  to  another  portion  of  the  ure- 
thra— the  region  lying,  in  round  figures,  at  about  two  to  three  inches  from 
the  meatus.  Ninety-nine  people  out  of  a  hundred  have  stricture  of  large 
calibre  in  this  region,  if  the  fact  that  this  portion  of  the  canal  is  smaller 
than  some  portion  of  the  canal  anterior  to  it  be  looked  upon  as  constitut- 
ing stricture,  as  many  men  of  the  present  day  seem  prone  to  believe. 
All  the  diagrammatic  charts  of  the  urethra  which  I  have  ever  seen  repre- 
sent the  canal  as  naturally  narrowing  down  in  this  region  to  expand  again 
into  a  sinus  before  the  final  narrowing  of  the  meatus.  This  condition 
exists  normally,  and  it  is  as  irrational  to  alter  it  theoretically,  and  as 
Quixotic  to  attempt  to  improve  upon  it  practically,  as  it  would  be  to  try 
to  give  every  one  a  Roman  nose  because  that  type  seems  the  most  noble. 

These  contractions  of  the  urethra  at  the  meatus  and  lower  down,  as 
they  are  ordinarily  encountered,  are  not  pathological.  They  vary  much, 
as  a  man's  mouth,  and  nose,  and  ears  vary  in  size  from  that  of  the  same 
organs  in  another.  The  contracted  meatus  is  not  due  to  a  tight  prepuce 
in  early  life,  or  to  lack  of  hygienic  care.  1  have  tested  a  number  of 
Israelites  who  have  had  no  foreskin  since  the  eighth  day  of  life,  and  I 
find  these  points  of  contraction  as  marked  in  them  as  in  the  Christian. 
Time  and  again,  in  examining  a  patient  for  one  thing  or  another,  not 
urinary  in  any  sense  (cases  of  chancre,  hernia,  skin  disease,  and  for 
morbid  conditions  of  the  testicle  not  inflammatory),  I  find  a  very  small 
meatus.  I  naturally  ask  for  symptoms,  but,  finding  none,  I  see  no  occa- 
sion to  interfere.  In  examining  for  stone  or  enlarged  prostate,  the  sec- 
ond point  of  narrowing,  at  two  inches  or  more,  may  usually  be  detected; 
but  if  it  occasions  no  symptoms,  since  it  certainly  does  not  cause  either 
the  stone  or  the  enlarged  prostate,  there  is  no  occasion  to  direct  any 
treatment  against  it. 

There  is  no  just  measure  of  size  for  the  urethra,  so  far  as  I  am  aware. 


STRICTURE    OF   LARGE   CALIBRE.  297 

The  arbitrary  decision  that  because  the  penis,  in  repose,  measures  three 
inches  in  circumference,  the  circumference  of  the  whole  course  of  the 
urethra  must  be  thirty  millimetres,  has  a  foundation  only  in  the  theoreti- 
cal accuracy  of  its  enthusiastic  originator.  The  circumference  of  a  man's 
penis  in  repose  varies  greatly — after  and  before  a  prolonged  sea-bath,  for 
instance,  and  under  other  circumstances,  as  I  have  verified  by  measure- 
ment. The  exhaustive  paper  of  Prof.  Sands,1  read  before  the  County 
Medical  Society,  and  ably  seconded  by  the  remarks  of  Prof.  Weir,"  bring- 
ing the  literature  of  the  subject  up  to  date,  and  showing  casts  of  the  ure- 
thra skilfully  executed  upon  the  bodies  of  four  seemingly  healthy  people 
•of  different  ages,  proved  conclusively  that  there  is  no  uniformity  in  size 
to  the  urethra,  and  no  regularity  about  it.  The  casts  in  Prof.  Sands's  pa- 
per show  numbers  of  constricted  points  which  might  be  readily  demon- 
strated to  be  strictures  by  the  urethrameter  in  a  willing  hand. 

The  demonstration  of  the  existence  of  these  bands  along  the  urethra 
is  very  easy  during  life.  They  may  uniformly  be  found.  The  larger  the 
•exploring  instrument,  the  more  bands  does  it  discover.  I  have  not  yet 
found  a  person  upon  whom  I  could  not  demonstrate  points  of  uneven  dil- 
.atability  along  the  urethra:  whether  such  person  were  healthy  or  the  sub- 
ject of  real  stricture;  whether  he  suffered  from  no  symptoms  or  had  a 
gleet;  whether  his  urethra  had  been  cut  internally  or  not;  whether  the 
symptoms  for  which  the  urethra  had  been  cut  had  yielded  to  the  treat- 
ment or  not.  I  do  not  know  that  this  experience  is  universal,  but  I  think 
it  must  be.  I  remember  one  poor  fellow,  whose  urethra  I  cut  again  and 
again  when  testing  this  method,  urged  on  by  the  patient  himself  and  for- 
tified by  the  advice  and  consent  of  experienced  men  in  consultation.  He 
did  not  get  well,  but  his  urethra  finally  reached  a  size  which  allowed  a  27 
American  (42  French)  conical  steel  sound  to  pass  easily  down  the  urethra 
into  the  bladder;  and  immediately  afterward,  a  No.  39  bulb  passed  up  and 
down  the  canal  detected  a  number  of  inequalities  and  linear  points  where 
the  canal  was  smaller  than  at  other  points.  One  of  these  bands  was  sit- 
uated internally,  at  a  point  corresponding  to  nearly  the  middle  of  the  fre- 
num  externally  (for  the  insertion  of  the  frenum  into  the  glans  penis  had 
been  utilized  in  order  to  enlarge  the  meatus),  and  the  poor  fellow  put  his 
index  finger  into  his  urethra  up  to  this  point,  and,  asserting  that  he  could 
feel  another  stricture  there,  begged  me  to  cut  it.  This  I  respectfully  de- 
clined to  do,  and  the  patient  shortly  disappeared  from  view,  doubtless  to 
seek  other  advice. 

Therefore  I  contend  that  all  urethral  canals,  healthy  or  unhealthy, 
will  yield  bands  of  irregular  constriction  to  any  one  exploring  with  a  large 
enough  instrument;  and  that,  too,  irrespective  of  the  cure  of  any  stricture 
which  may  have  been  cut,  or  of  the  symptom  (gleet  usually)  for  which  it 
may  have  been  cut.  Consequently,  the  existence  of  these  bands  in  the 
anterior  portions  of  the  urethra  does  not  constitute  stricture,  and  stricture 
may  be  cured  while  they  still  remain  behind. 

Finally,  and  most  positive  evidence  of  all,  I  have  the  anatomical  proof 
that  these  bands  do  not  constitute  stricture.  Some  years  ago  I  had  the 
good  fortune  to  be  present  at  a  post-mortem  examination  upon  the  body 
of  a  patient  who  died  at  a  certain  short  interval — I  think  it  was  about  two 
weeks — after  perineal  section  for  impermeable  stricture,  and  after  having 
had  a  number  of  strictures  in  his  pendulous  urethra  divided  by  Dr.  Otis, 

1  New  York  Medical  Journal,  March,  1876,  p.  225. 

2  Ibid.,  April,  1876,  p.  377. 


298  THE    VENEREAL    DISEASES. 

with  his  dilating  urethrotome.  Dr.  George  Peters  had  verified  the  pres- 
ence of  these  numerous  strictures  before  the  operation;  Dr.  McBurney 
made  the  autopsy.  I  did  not  learn  clearly  of  what  the  patient  died,  but 
I  believe  death  was  ascribed  to  the  kidney.  Dr.  Bumstead  and  myself,  in 
the  evening,  went  to  the  house  of  Dr.  Otis  to  examine  the  patient's  ure- 
thra. The  line  of  the  cut  could  be  seen,  but  the  mucous  membrane  along 
the  whole  course  of  the  cut  on  either  side  seemed  absolutely  sound  to  the 
eye  and  to  the  finger.  No  hardness,  110  bands  could  be  detected.  Dr. 
Otis  reserved  the  specimen  for  careful  examination  by  the  microscope. 
The  result  of  that  examination  I  have  not  seen  reported. 

In  one  of  the  cases  of  death  alluded  to  by  Dr.  Sands,  the  floor  of  the 
urethra  at  the  autopsy  was  found  divided  anteriorly  to  the  extent  of  three 
and  a  half  inches;  the  mucous  membrane  was  not  thickened,  and  "  showed 
no  appearance  of  disease  to  the  naked  .eye."  "A  tight  organic  stricture, 
undivided,  was  noticeable  at  the  bulbo-membranous  junction."1  In  this 
case  death  occurred  on  the  sixteenth  day,  from  uraemia. 

At  this  point  it  seems  desirable  to  inquire  what  it  is,  then,  that  consti- 
tutes stricture  of  large  calibre  in  the  anterior  urethra,  and  when  it  is  ne- 
cessary for  the  surgeon  to  interfere.  In  answer  it  may  be  said:  stricture 
of  large  calibre  of  the  anterior  urethra  does  exist  when  an  exploring  in- 
strument passed  gently  through  a  physiologically  contracted  area  draws 
blood  (on  account  of  an  erosion  or  a  granular  condition  of  the  membrane 
at  this  point),  or  when  the  physiological  condition  is  carried  to  an  excess, 
as,  for  instance,  when  the  ineatus  is  only  as  large  as  a  knitting-needle. 
How  small  the  second  or  other  contracted  points  of  the  urethra  must  be 
to  constitute  stricture,  I  do  not  know;  and  I  consider  it  as  unimportant  as 
I  do  the  size  of  the  rectum  at  one  of  its  natural  points  of  constriction — the 
sphincter  tertius,  the  point  of  reflection  of  the  peritoneum.  Stricture 
may  also  certainly  be  said  to  exist  when  it  may  be  felt  as  a  fibrous  band 
from  the  outside,  after  a  full  dilating  solid  instrument  has  been  passed 
through  it.  None  of  the  physiological  bands  can  be  so  felt,  while  the 
inodular  deposits  can  always  be  felt. 

Finally  comes  the  really  practical  question :  When  should  a  surgeon  in- 
terfere with  instruments  in  the  treatment  of  stricture  of  large  calibre  of 
the  anterior  urethra?  The  proper  answer  I  believe  to  be,  never  until  the 
occurrence  of  symptoms  calls  for  interference.  This  rule,  like  all  others, 
has  its  exceptions.  I  believe,  however,  that  it  holds  absolutely  for  all 
congenital  strictures  of  the  meatus,  unless  they  are  very  tight,  and  for 
some  strictures  in  this  region  the  result  of  cicatrices.  It  holds  also  for 
that  (we  may  call  it)  physiological  band  of  constriction  often  found  just 
within  the  meatus,  at  about  one-fourth  of  an  inch  or  thereabouts,  and  cer- 
tainly for  the  deeper  bands  in  the  pendulous  urethra.  It  is  exceedingly 
rare  for  any  stricture  of  large  calibre  of  the  anterior  urethra  to  close  so 
tightly  as  to  give  rise  to  serious  urinary  complications  (leaving  spasmodic 
stricture  from  reflex  action  out  of  the  question),  except  the  variety  known 
as  inodular  stricture,  and  stricture  resulting  from  a  cicatrix  of  the  meatus. 
Both  of  these  forms  of  stricture,  then,  may  be  appropriately  attacked  before 
they  have  given  rise  to  any  symptoms — stricture  of  the  meatus,  and  inod- 
ular stricture  of  the  pendulous  urethra — such  a  stricture  as  may  be  felt 
like  a  ferule,  or  a  lumpy  band  around  a  solid  instrument  which  has  been 
introduced  through  it. 

Symptoms  of  stricture  of  large  calibre. — These  strictures  may 

1  L.  c.,  p.  135. 


STRICTURE    OF    LARGE    CALIBRE.  299 

give  rise  to  spasmodic  and  irritable  troubles  in  the  deep  urethra,  symptoms 
of  cystitis,  sciatica,  and  of  the  most  varied  nervous  functional  troubles  in 
different  parts  of  the  body.  When  they  do  so  act,  however,  they  are 
themselves  generally  more  or  less  sensitive,  sometimes  inflamed  and  gran- 
ulating upon  their  surface.  Sometimes,  on  the  other  hand,  especially  at 
the  meatus,  such  strictures  are  neither  inflamed  nor  sensitive,  and  it  often 
becomes  a  very  nice  question  to  decide  whether  they  have  anything  to  do 
with  troubles  deeper  in  the  canal  or  not. 

The  vast  majority  of  these  strictures,  according  to  my  experience,  pro- 
duce no  symptoms  whatsoever,  excepting  a  slight  gleet,  and  very  many 
of  them  not  even  that.  Before  deciding  that  a  given  tight  spot  in  the 
urethra  is  the  cause  of  other  trouble  deeper  in  the  canal,  it  is  wise  to  elim- 
inate all  other  sources  of  such  trouble,  and  not  to  jump  at  the  conclusion 
that  because  there  are  bands  in  the  urethra,  and  spasmodic  or  inflamma- 
tory trouble  farther  down,  the  latter  necessarily  depends  upon  the  former, 
and  will  be  relieved  by  a  cutting  operation.  Such  a  doctrine  must  cer- 
tainly sooner  or  later  lead  a  young  man  to  the  border-line  of  quackery,  if 
not  into  its  domain. 

In  cases  of  grave  doubt  the  surgeon  is  certainly  justified  in  operating 
upon  strictures  with  the  knife,  and  if  no  good  comes  of  it  he  cannot  be 
blamed;  but  he  should  only  decide  to  act  after  due  deliberation  and  a 
careful  study  of  his  case.  The  meatus  and  first  inch  of  the  canal  may  be 
cut  with  far  more  impunity,  and  to  a  greater  extent,  if  necessary,  than 
any  other  portion  of  the  canal. 

The  most  common  symptom  of  strictures  of  large  calibre  in  the  pendu- 
lous, or  in  the  deep  urethra,  is  a  gleet,  more  or  less  purulent. 

Diagnosis. — When  a  stricture  of  large  calibre  is  important  enough 
to  yield  any  symptom  besides  the  possible  (but  improbable)  spasmodic 
and  reflex  irritative  phenomena  referred  to  and  the  gleet,  there  are  cer- 
tain physical  means  of  diagnosis  which  yield  quite  accurate  results.  One 
quite  constant  symptom,  really  analogous  to  gleet,  is  the  occurrence  of 
little  thread-like  bodies,  snaky  rolls  of  white  material  which  float  around 
in  the  freshly  voided  urine,  gradually  sinking  to  the  bottom  of 
the  vessel.  These  are  clusters  of  pus-corpuscles  which  have 
gathered  upon  the  excoriated  and  granular  surface  of  the  ure- 
thra at  and  behind  the  stricture,  like  soft  scabs,  and  are  washed 
off  by  the  stream  of  urine  in  its  passage.  They  can  be  easily 
caught  in  a  pipette  and  examined  with  the  microscope.  These 
shreds  of  pus-cells  are  not  pathognomonic,  since  they  occasionally 
come  from  the  prostatic  urethra;  but  they  seldom  do  so,  and  gen- 
erally indicate  stricture  of  the  urethra. 

The  clinical  diagnosis  of  stricture  of  large  calibre  is  easy  and 
satisfactory.  A  bulbous  bougie  (Fig.  30),  preferably  of  metal, 
as  large  as  the  meatus  will  take,  may  be  warmed  and  anointed 
with  vaseline,  and  gently  passed  through  the  urethra.  When  it 
comes  to  a  tight  spot  the  surgeon  can  feel  it  as  well  as  the  pa- 
tient. If  this  spot  is  the  seat  of  the  gleety  discharge,  the  bulb 
of  the  instrument  is  very  apt  to  be  faintly  tinged  with  blood  at  its  tip  upon 
withdrawal.  Points  of  stricture  are  often  sensitive;  their  length  may  be 
measured  by  the  aid  of  this  bulbous  instrument  and  their  number  ascer- 
tained, if  more  than  one  exist.  This  exploration  refers  only  to  the  pen- 
dulous urethra. 

If,  on  attempting  this  exploration,  congenital  or  pathological  narrow- 
ing of  the  orifice  of  the  urethra  be  found  to  exist,  the  canal  ma}'  still  be 


300 


THE    VENEREAL    DISEASES. 


explored  without  cutting  the  meatus,  by  the  use  of  the  very  ingenious  ex% 
panding  urethrameter  (Fig.  31)  devised  by  Dr.  Otis.  This  instrument  A 
is  introduced  closed  B,  capped  with  a  piece  of  thin  rubber  C,  down  to  the 
sinus  of  the  bulb.  It  is  there  to  be  expanded  until  the  patient  feels  a 
slight  distention,  and  then  to  be  slowly  withdrawn  toward  the  meatus. 
Upon  encountering  resistance  the  handle  is  turned  so  as  to  make  the  size 
of  the  bulb  smaller,  all  changes  in  the  bulb  being  marked  upon  an  index- 
plate  at  the  handle.  The  shaft  of  the  instrument  is  marked 
in  inches,  and  by  its  aid  all  constrictions  in  the  canal  may  be 
accurately  located,  measured,  and  calibrated. 

In  short,  exploration  by  this  instrument  leaves  nothing  to 
desire,  excepting  a  point  of  departure.  Here,  unfortunately, 
it  fails,  for  it  has  to  assume  either  that  the  size  of  some  por- 
tion of  the  canal  is  the  natural  size  of  the  whole  course  of  the 
urethra  (which  is  manifestly  inaccurate,  as  has  been  shown), 
or  the  surgeon  has  to  assume  some  arbitary  dimension  as 
being  the  proper  size  of  the  urethral  canal,  and  in  this  he  is 
as  apt  to  be  wrong  as  to  be  right,  the  danger  being  that  he 
will  overestimate  the  size  of  the  canal,  because  he  starts  in 
one  of  its  widest  natural  pouches. 

Moreover,  with  this  instrument,  damage  is  apt  to  be  in- 
flicted upon  a  sensitive  urethra,  which  may  and  often  does 
lead  (as  I  have  witnessed)  to  an  aggravation  of  all  the  symp- 
toms for  which  the  exploration  was  made,  and  to  the  lighting 
up  of  new  ones  (cystitis,  epididymitis).  This  instrument  dose 
excellent  service  at  times,  mainly  in  the  way  of  accurately 
locating  strictures  in  the  pendulous  urethra,  which  the  sur- 
geon has  decided  should  be  cut. 

When,  therefore,  the  meatus  is  small  and  the  urethra 
has  to  be  explored,  the  stricture  of  the  meatus,  and  any 
tight  spot  within  the  first  three-quarters  of  an  inch  from  the 
meatus,  may  be  cut  at  once  as  a  part  of  the  examination.  If 
the  meatus  alone  is  involved,  it  may  be  cut  down  to  the 
bottom  of  any  pouch  lying  behind  either  of  its  angles,  and 
fully  two  sizes  (American  scale)  larger,  for  in  healing  it  will 
contract  somewhat,  and  it  should  be  left  so  that  when  well 
it  may  be  at  least  physiologically  large.  Any  band  smaller 
than  the  new  cut  meatus  and  lying  near  it  should  also  be  cut 
at  the  same  sitting,  as  part  of  the  examination. 

This  course  is  advised  for  several  reasons.  First,  the  ure- 
thra cannot  be  properly  explored  from  before  backward  with 
a  bulbous  bougie,  unless  the  orifice  of  the  urethra  will  admit 
the  passage  of  a  fair-sized  bulb. 

Secondly,  no  organic  stricture  deeper-seated  can  be  treated 
with  sufficiently  large  instruments  unless  the  meatus  is  pre- 
pared for  their  reception. 

Thirdly,  no  treatment  will  cure  a  stricture  at  or  near  the 
meatus,  except  the  knife,  so  far  as  I  know. 

Fourthly,  the  operation  itself  is  trivial  in  importance,  pains  but  little, 
never  calls  for  the  use  of  an  anesthetic,  and  never,  in  my  experience,  when 
performed  upon  an  urethra  which  would  tolerate  any  interference  what- 
ever or  was  fit  for  any  examination,  has  given  rise  to  any  complication 
or  subsequent  discomfort.  When  practised  alone  I  never  have  seen  it 
cause  urethral  chill,  or  irritation  of  the  canal,  or  epididymitis,  or  cystitis. 


FIQ.  31. 


STRICTUKE    OF   LAKGE    CALIBKE.  301 

The  simultaneous  use  of  the  sound  upon  the  deep  urethra,  however,  may 
cause  any  of  these  complications. 

The  meatus  then  should  be  cut  a  little  larger  than  full  size,  and  the 
bulb,  then  introduced  as  through  a  natural  meatus,  will  detect  strictures 
in  the  pendulous  uretha,  if  there  be  any. 

Stricture  of  large  calibre  of  the  deep  urethra  may  be  sought  for  with  a 
blunt  (not  a  conical),  well-warmed  steel  sound  of  a  size  as  large  as  the  an- 
terior urethra  will  admit.  If  there  be  spasmodic  stricture  of  the  deep  ure- 
thra, such  an  instrument,  in  my  experience,  will  always  go  in  if  properly 
handled.  It  is  written  on  good  authority  that  this  will  not  always  occur, 
and  I  must  therefore  believe  it ;  but  personally,  after  considerable  experience 
I  can  say  that  I  have  never  met  a  case  which  I  believed  to  be  spasmodic 
stricture  in  which  I  could  not  pass  a  blunt  sound  in  the  way  I  shall  de- 
scribe, and  certainly  I  have  never  cut  a  case  of  spasmodic  stricture  by  the 
perineal  section;  for,  in  all  my  cases  of  this  operation — some  done  with  and 
some  without  a  guide — I  have  invariably  been  able  to  see  and  to  feel  the  mor- 
bid tissue  constituting  the  stricture  in  the  b»ttom  of  the  perineal  wound. 

I  believe  also  that  a  spasmodic  stricture  of  the  urethra  must  necessarily 
yield  under  ether  and  allow  the  passage  of  a  full-sized  blunt  sound,  not- 
withstanding a  recent  case  reported  to  the  contrary  by  Dr.  Otis. 

The  blunt  sound,  well  warmed  and  oiled,  should  be  gently  carried  down 
the  urethra  and  its  beak  presented  accurately  at  the  hole  in  the  triangu- 
lar ligament.  Here  it  should  be  held  under  even  pressure — rather  firm, 
but  not  violent — a  perfectly  uniform  pressure  and  with  a  very  steady  hand, 
for  several  minutes,  perhaps  five,  or  possibly  more.  The  patient,  mean- 
time, should  be  entertained  and  diverted,  pleasantly  if  possible — the  scro- 
tum being  held  well  up  by  the  unemployed  hand,  which  at  the  same  time 
steadies  the  beak  and  the  curve  of  the  instrument  through  the  perineum. 
If  under  such  a  manoeuvre  the  sound  does  not  presently  slip  along  and 
glide  smoothly  and  rather  swiftly  into  the  bladder,  it  is,  I  believe,  always 
either  because  the  stricture  is  not  spasmodic,  or  because  the  beak  of  the 
instrument  has  not  been  properly  brought  to  bear  upon  the  cramped  muscles. 

Treatment. — Stricture  far  forward  in  the  urethra  must  be  cut  to  be 
cured.  This  is  most  conveniently  done  with  a  straight,  blunt  bistoury. 
The  prepuce  should  be  retracted,  the  previously  dried  head  of  the  penis 
seized  between  the  thumb  and  index  finger  of  the  left  hand,  and  the  blade 
of  the  knife,  well  oiled,  introduced  to  the  proper  depth  in  the  urethra.  It 
is  generally  best — often  Accessary  on  account  of  the  pocket — to  cut  the 
meatus  along  the  floor  of  the  urethra;  but  in  some  peculiar  shapes  of  the 
glans  penis  it  may  be  better  to  cut  the  roof  of  the  urethra. 

When  all  is  ready  the  surgeon  squeezes  the  glans  penis  tightly  with 
the  thumb  and  finger  which  hold  it,  since  this  diminishes  the  patient's 
perception  of  the  pain  of  the  cut,  and  at  the  same  moment  slowly  and 
steadily  draws  the  well-oiled  sharp  blade  along  the  floor  of  the  urethra, 
appreciating  with  his  surgical  sense  of  touch  the  resistance  offered  to  the 
knife  by  the  encircling  band  of  stricture.  When  this  yields  and  is  thor- 
oughly cut  through,  he  can  appreciate  it  at  once  by  a  cessation  of  the 
feeling  of  resistance  which  the  band  has  given,  and  he  has  cut  enough.  If 
it  is  only  a  pouched  meatus  which  the  surgeon  has  to  transform  into  a  slit, 
he  regulates  his  incision  accordingly.  Civiale's  or  any  other  meatotome 
may  be  used,  if  the  surgeon  prefers.  Dr.  Otis  advises  the  operator  to 
place  the  index  finger  of  his  left  hand  along  the  integument  beneath  the 
urethra,  so  that  the  stricture  band  may  be  felt  between  the  finger  and  the 
knife.  In  this  position  he  cuts  directly  upon  the  finger  until  he  can  feel 


302 


THE    VENEREAL   DISEASES. 


the  point  of  the  knife  against  the  soft  tissues  and  appreciate  the  absence 
of  the  band  between  the  finger  and  the  knife.  This  is  an  excellent 
method — better  in  many  cases  than  any  other. 

The  cut  meatus  sometimes  bleeds  profusely,  sometimes  hardly  at  all. 
The  expedients  for  stopping  blood  are:  pressure  for  a  time,  followed  by 
collodion  applied  in  several  coats  to  the  well-dried  meatus  while  it  is  held 
together  under  pressure,  to  keep  the  blood  from  oozing  while  the  collodion 
is  drying  on;  or  a  small  roll  of  absorbent  cotton  soaked  in  pure  subsul- 

phate  of  iron,  which  may  be  introduced 
into  the  bottom  of  the  cut  with  a  probe. 
There  is  never  any  danger  from  possible 
excess  of  bleeding,  for  the  patient  can  al- 
ways stop  the  haemorrhage  until  the  sur- 
geon arrives,  by  digital  pressure,  and  the 
surgeon  can  always  finally  arrest  it  by  in- 
jecting the  urethra  with  the  liquid  subsul- 
phate  of  iron  diluted  about  one-half.  It 
is  better  not  to  put  subsulphate  of  iron  into 
the  urethra,,  if  it  can  be  avoided,  since  this 
substance  is  apt  to  leave  the  walls  of  the 
canal  inflamed,  hardened,  and  ready  to 
suppurate.  Much  time  in  the  treatment 
may  be  lost  on  account  of  the  use  of  this 
haemostatic. 

When  there  is  little  or  no  bleeding, 
some  cotton  or  lint,  so  arranged  as  to  be 
retained  beneath  the  prepuce,  is  all  that  is 
required. 

A  cut  orifice  will  heal  up  immediately 
if  left  to  itself.  My  usual  plan  to  prevent 
this  is  to  furnish  the  patient  with  a  hair- 
pin, with  the  curved  portion  rebent  and 
the  angle  much  increased  in  size,  so  as  to 
be  large  enough  when  oiled,  and  passed 
down  the  urethra,  to  lie  with  one  leg  of 
the  pin  against  the  roof  of  the  urethra,  the 
other  leg  at  the  bottom  of  the  whole  length 
of  the  wound,  while  the  two  points  are 
oxitside.  I  tell  the  patient  to  pass  this  on 
the  night  after  being  cut,  and  on  the  fol- 
lowing two  nights  ;  then  to  skip  a  night 

for  two  passages  ;  then  to  skip  two  nights  for  three  passages  of  the  pin. 
By  the  end  of  this  time  (a  full  fortnight)  the  meatus  has  often  healed 
entirely,  or  so  nearly  that  it  may  be  left  to  itself,  and,  if  thoroughly  cut 
and  healed  open,  it  never  recontracts.  » 

The  treatment  most  appropriate  for  all  other  organic  strictures  of 
large  as  well  as  small  calibre,  is  by  dilatation  at  first.  Should  this  fail, 
other  means  are  at  hand.  Steel  instruments,  nickelled,  conical  in  shape, 
are  most  serviceable,  arid  do  the  most  accurate  as  well  as  the  most  effec- 
tive work  in  dilating  the  canal,  either  pendulous  or  deep,  provided  the 
size  of  the  instrument  is  as  large  as  No.  10  American  (15  French).  Should 
the  stricture  be  smaller  than  this  size,  soft  instruments  are  best  to  com- 
mence with. 

The    conical  instrument   (Fig.  32)  tapers   for  two  and  three-quarter 


Fio.  32. 


STRICTURE    OF    LARGE    CALIBRE.  303 

inches,  and  should  be  made  upon  what  is  called  the  short  curve,  with  an 
extra  shortness  of  the  curve  at  the  last  half-inch  near  the  beak,  since  this 
extra  curve  greatly  facilitates  introduction,  especially  at  the  hole  in  the 
triangular  ligament,  by  keeping  the  point  of  the  instrument  against  the 
roof  of  the  canal.  Such  an  instrument,  as  large  as  the  stricture  will  admit, 
well  oiled  and  warmed,  should  be  passed  with  great  gentleness  well  into 
the  bladder.  The  power  of  the  instrument  is  great,  being,  as  it  is,  a  com- 
pound of  wedge  and  lever,  and  the  surgeon  should  exercise  considerable 
self-control,  so  as  not  to  abuse  that  power.  The  passage  of  one  such  in- 
strument as  this  is  equivalent  to  the  passage  of  seven  sounds  of  the  old 
blunt  pattern,  since  the  conicity  in  the  larger  instruments  extends  through 
seven  sizes. 

The  instrument  is  to  be  introduced,  and  then,  very  gently,  immediately 
withdrawn.  At  the  first  sitting  only  one  sound  should  be  passed — a  sound 
of  moderate  size. 

The  time  most  appropriate  for  a  reintroduction  of  the  steel  sound  in 
a  case  of  stricture  of  large  calibre  must  be  determined  by  the  effect  pro- 
duced by  the  instrument  upon  its  trial  trip.  The  immediate  effect  is 
•often  only  an  increase  in  the  amount  of  pain  experienced  during  urina- 
tion. After  a  day  or  two  the  discharge  from  the  urethra  often  visibly  in- 
creases; but  this  subsides  spontaneously,  or  by  the  aid  of  a  very  mild  in- 
jection, and  at  the  end  of  four  or  five  days  the  symptoms  for  which  the 
sound  was  introduced  have  reached  the  same  grade  as  that  at  which  they 
existed  at  the  moment  of  the  first  introduction  of  the  sound.  .  Twenty- 
four  hours  should  now  be  allowed  to  pass,  or  even  forty-eight,  and 
then  a  sound  of  one  or  two  sizes  larger  may  be  gently  passed  into  the 
urethra. 

The  result  of  this  second  instrumentation  is  that  the  symptoms  are  less 
aggravated  by  it  than  they  were  by  the  first,  improvement  arrives  a  little 
sooner,  is  more  marked,  and  remains  longer.  In  this  way,  increasing  the 
sizes,  and  using  on  each  occasion  a  conical  sound  as  large  as  will  pass,  the 
symptoms  generally  yield  entirely,  and  the  patient  is  well.  The  most 
effective  treatment  by  large  instruments  is  that  which  leaves  an  interval 
of  one  week  between  the  passages  of  the  sound. 

After  the  symptoms  have  disappeared  the  treatment  should  be  discon- 
tinued gradually.  In  some  mild  cases  of  stricture,  not  resilient  and  not 
traumatic,  treatment  may  be  suspended  entirely  after  a  few  weeks,  and 
the  patient  is  and  remains  well  for  the  rest  of  his  life,  excepting  that  he 
is  capable  of  getting  a  new  gleet  from  a  lighter  cause  than  if  he  had  never 
had  stricture.  If  he  does  not  expose  himself,  however,  to  the  causes  of 
urethritis,  he  may  marry  and  remain  well  for  the  rest  of  his  days,  in  most 
instances,  without  ever  showing  any  symptoms  of  lack  of  health  in  his 
urinary  or  genital  apparatus.  This  is  especially  true  concerning  strictures 
of  large  calibre  of  the  pendulous  urethra,  those  for  which  such  splendid 
results  in  the  way  of  radical  cure  are  claimed  by  the  advocates  of  the  per- 
petual use  of  the  knife.  Truly,  in  these  cases  cured  by  dilatation,  the 
urethrameter,  if  screwed  up  to  make  the  bulb  large  enough,  will  detect 
tight  places  along  the  pendulous  urethra  after  cure;  but  so  it  would  have 
done  when  the  patient  was  virgin  of  all  disease,  and  I  have  already  shown 
that  tight  places  in  the  pendulous  urethra,  without  symptoms,  cannot  be 
regarded  as  strictures  at  all. 


304  THE    VENEREAL    DISEASES. 


RESILIENT   STRICTURES    OF   LARGE    CALIBRE. 

There  is  a  class  of  strictures  in  the  pendulous  urethra  which  produce 
varied  symptoms — generally  gleet — and  which  do  not  yield  entirely  to  dila- 
tation, nor  do  their  symptoms  disappear  under  the  use  of  the  steel  sound. 

These  cases  belong  to  one  of  two  groups:  either  (1)  the  patient's  gen- 
eral health  is  such  that  local  means  will  not  (alone)  cure  him,  as  is  known 
to  be  so  often  the  case  in  catarrhal  affections  of  other  mucous  membranes 
attended  by  thickening;  or  (2)  the  stricture  is  resilient  and  does  not  yield 
to  dilatation. 

Regarding  the  first  class,  the  patient's  general  condition  must  be  stud- 
ied, and  especially  his  sexual  hygiene.  I  have  known  many  a  case  to  get 
well  and  to  stay  well,  without  there  being  any  necessity  for  a  continuation 
of  the  use  of  instruments  in  the  urethra,  and  this  cure  has  been  effected 
simply  by  marriage,  after  all  other  means,  including  extreme  dilatation 
and  extreme  cutting,  had  failed. 

I  have  known  others  to  get  well  promptly  by  a  sea-voyage,  change  of 
climate,  a  prolonged  trip  to  the  country,  when  extreme  cutting,  by  the 
best-known  advocates  of  this  plan,  has  failed  to  give  relief. 

Then  there  are  cases  of  gleet  associated  with  tubercle,  with  prostatic 
disease,  with  chronic  inflammatory  trouble  in  the  seminal  vesicles,  in  which 
it  is  folly  to  attempt  a  cure,  either  by  dilatation  or  by  cutting  any  or  all 
of  the  bands  and  tight  places  in  the  pendulous  urethra  which  the  urethra- 
meter  or  bulbous  sound  can  be  made  so  easily  to  detect. 

But,  finally,  the  second  group  of  strictures  of  large  calibre  remains. 
They  are  resilient,  that  is,  they  have  in  them  that  tenacious,  cicatricial, 
retractile  quality  which  does  not  allow  dilatation  to  affect  them  favorably 
beyond  a  certain  point.  The  symptoms  yield,  but  do  not  entirely  disap- 
pear. A  little  gleet  in  the  morning  continues  to  mock  the  efforts  of  the 
surgeon  and  to  disgust  the  patient  with  his  disease,  and  often  with  the 
science  of  medicine.  In  these  cases,  after  being  certain  to  locate  the 
symptoms  accurately  in  the  stricture,  and  not  to  be  deceived  by  ascribing 
gleet  due  to  diathetic  or  other  cause  to  a  tight  spot  found  in  the  urethra, 
the  surgeon  may  employ  internal  urethrotomy  within  the  pendulous 
urethra.  Under  these  circumstances,  the  operation  offers  a  good  chance 
of  success  in  ridding  the  patient  both  of  the  final  remains  of  his  symptoms 
and  of  the  necessity  for  a  continuation  in  the  use  of  sounds — if  the  sur- 
geon cuts  wide  enough  at  any  one  point  and  passes  entirely  through  the 
unyielding  contractile  ring  of  stricture.  This  ring  of  modular  tissue  is 
white,  fibrous-like,  cicatricial  tissue,  and  not  the  yellow  elastic  fibres  which 
Robin  and  Cadiat  have  found  so  abundantly  in  the  structure  of  the  healthy 
urethral  mucous  membrane. 

The  treatment  by  internal  urethrotomy,  however,  is  only  generally 
applicable  to  the  pendulous  urethra.  All  organic  strictures  at  or  deeper 
than  the  bulbo-membranous  junction  should  be  treated  by  dilatation  alone — 
by  dilatation  to  the  greatest  limit  to  which  it  can  be  carried  with  gentle- 
ness, and  this  will  cure  the  symptoms,  or  so  nearly  cure  them  that  most 
sensible  men  who  are  made  familiar  with  the  dangers  of  internal  urethro- 
tomy in  the  curved  portion  of  the  urethra  will  be  satisfied  with  the  result. 

Such  a  cure,  or  relative  cure  of  stricture  in  the  deep  urethra,  espe- 
cially in  bad  cases  of  modular  stricture,  cannot  be  maintained  excepting 
at  the  expense  of  constant  dilatation.  The  patient  is  condemned  to  pass 
an  instrument,  at  such  intervals  as  may  be  found  necessary  (from  once  a 


STRICTURE    OF   LARGE   CALIBRE.  305 

week  to  once  a  month,  after  a  time  at  longer  intervals),  for  the  remainder 
of  his  life,  in  order  to  keep  down  his  symptoms  and  to  prevent  the  recon- 
traction  of  his  stricture.  And  this  is  still  the  case,  no  matter  by  what 
treatment  the  urethra  has  been  brought  to  such  a  size  as  to  allow  the 
passage  of  a  full-sized  instrument  into  the  bladder.  Repeatedly  does  the 
surgeon  find,  in  hospital  and  dispensary  practice,  cases  of  tight  stricture 
in  the  curved  urethra,  which  have  already  been  subjected  once,  twice,  or 
perhaps  three  times  to  internal  urethrotomy,  or  even  to  external  urethro- 
tomy. I  have  performed  perineal  section  more  than  once  under  each  of 
these  circumstances,  where  the  patients,  from  neglect  to  pass  the  sound 
continuously  after  a  former  cutting,  had  allowed  the  urethra  to  close  at 
the  point  of  stricture.  And  I  have  treated  a  large  number  by  dilatation, 
after  recontraction  had  followed  the  cutting  operation. 

Stricture  of  large  calibre  in  the  pendulous  urethra  may  be  cured  by  a 
variety  of  means,  so  that  its  symptoms  may  cease  forever,  without  the 
necessity  for  any  further  use  of  instruments  in  the  canal. 

The  same  is  true  regarding  the  treatment  of  a  mild  stricture  of  the 
deep  urethra  cured  by  dilatation. 

Resilient  stricture  of  large  calibre  in  the  pendulous  urethra  is  often 
incurable  except  by  the  knife;  and  internal  urethrotomy,  if  the  cut  be 
large  enough,  will  generally  cure  the  symptoms  of  such  a  stricture  so  that 
they  will  not  return,  although  no  instruments  are  used  in  the  urethra 
after  the  cut  is  well. 

Small  organic  strictures  in  the  pendulous  urethra  are  probably  always 
best  managed  by  internal  urethrotomy. 

Strictures  of  the  deep  urethra,  when  organic  and  situated  at  or  be- 
yond the  bulbo-membranous  junction,  cannot,  all  of  them,  with  certainty 
be  radically  cured  by  any  operation  or  by  any  treatment  with  which  I 
am  familiar.  The  best  treatment  in  these  cases  is  always  dilatation  when 
practicable.  Sometimes,  after  dilatation  has  been  maintained  for  a  long 
period,  the  tendency  to  recontraction  ceases,  and  the  patient  remains  well, 
so  far  as  symptoms  are  concerned,  without  the  necessity  of  any  further 
instrumentation  in  the  urethra.  Possibly  a  like  cure  may  occasionally 
follow  internal  urethrotomy — I  have  known  it  to  follow  external  urethro- 
tomy in  one  case;  but,  in  the  majority  of  instances  of  inodular,  organic 
and  traumatic  strictures  of  the  deep  urethra,  a  cure  is  not  obtained  radi- 
cally by  any  operation  yet  known,  and  the  patient's  safety  consists  in  a 
maintenance  of  the.calibre  of  his  urethra  by  the  occasional  passage  of  a 
full-sized  instrument  through  the  obstruction  for  the  rest  of  his  life — a 
task  not  considered  at*  all  difficult  by  those  who  do  it. 


INTERNAL   URETHROTOMY    IN    THE    PENDULOUS    URETHRA. 

If,  then,  internal  urethrotomy  has  become  necessary  in  the  treatment 
of  a  stricture  of  large  calibre  of  the  pendulous  urethra,  which  of  the  nu- 
merous instruments  for  performing  the  operation  shall  be  used,  and  to 
what  limit  in  size  shall  the  urethra  be  cut  ? 

I  have  tried  nearly  all  the  improved  modern  urethrotomes,  and  have 
found  none  so  good  as  the  dilating  urethrotome  of  Dr.  Otis,  for  dealing 
with  such  strictures  as  have  to  be  cut  in  the  pendulous  urethra;  and  I 
must  repeat  that,  in  my  opinion,  deeper-seated  strictures  of  large  calibre 
should  not  be  cut  internally,  for  the  double  reason  that:  1.  Cutting  in  this 
region  is  a  proceeding  dangerous  to  life  ;  and,  2.  Cutting  in  this  region 
20 


306 


THE    VENEREAL   DISEASES. 


does  not  produce  a  radical  cure,  nor  allow  the  patient  to  dispense  with  a 
continual  use  of  the  sound  to  keep  his  stricture  open;  or  it  does  this  so 
seldom  that  its  curative  action  cannot  be  relied  upon,  and  the  hope  of 
cure  does  not  justify  the  risk  incurred  by  external  cutting. 

Otis's  instrument  is  quite  simple  and  strong.     It  is  a  happy  modifica- 
tion of   a  number  of  previous  types,  so  combined  as  to  form  an  instru- 
ment which  performs  its  functions  very  accurately.     It  consists  (Fig.  33) 
of  a  shaft,  the  blades  of  which  may  be  separated  by  a 
screw-movement  in  the  handle,  and  a  small  knife   con- 
cealed near  the  distal  end  of  one   of  the  blades,  which 
is    drawn    up   upon   a    concealed  bridge,  and  brought 
into  action  when  its  handle  at  the  proximal  end  of  the 
instrument  is  pulled  upon.     A  dial-plate  in  the  handle 
registers  the  degree  of  separation  of  the  blades. 

To  use  this  instrument,  with  the  urethrameter  or  bul- 
bous sound,  the  location  and  extent  of  the  stricture  to 
be  cut  are  at  first  definitely  decided  upon.  Then  the 
urethrotome  is  introduced  (dial-plate  and  knife  upper- 
most, as  a  rule)  so  deeply  that  the  point  at  which  the 
knife-blade  shall  emerge  shall  be  at  least  three-quarters 
of  an  inch  deeper  in  the  urethra  than  the  deepest  limit 
of  the  stricture.  This  I  find  necessary  in  all  strictures 
of  large  calibre;  without  it  the  deepest  parts  of  the 
stricture — those  most  distant  from  the  meatus — are  not 
cut.  For  I  find  that  the  lower  blade  of  the  instrument, 
in  opening,  pushes  away  the  urethra,  making  it  slide 
back  from  the  upper  blade;  so  that,  no  matter  how  ac- 
curately the  meatus  may  be  held  against  the  shaft  of  the 
urethrotome,  the  position  of  the  knife  relatively  to  the 
stricture  slides  forward  proportionately  to  the  amount 
of  separation  of  the  blades,  and  therefore,  when  the 
knife  is  brought  into  action,  it  may  commence  the  cut 
entirely  in  front  of  the  deepest  (often  the  tightest)  por- 
tion of  the  stricture,  unless  special  care  be  taken  to  avoid 
this  mishap. 

When  the  instrument  has  been  properly  placed,  the 
blades  are  separated  until  they  mark  the  size  to  which 
Jjj  it  is  desired  to  cut  the  stricture.     In  cutting,  the  handle 

of  the  knife  is  withdrawn  far  enough  to  make  the  cut 
\  in  all  at  least  half  an  inch  longer  than  it  was  originally 

r        j?          decided  that   the   stricture   measured.      Now  the  blades 
^    ^^  are  to  be  rapidly  approximated,  and  the  knife  returned 

Fio.  33.  to  its  concealment  before  withdrawing  the  instrument. 

If  other  strictures  exist  farther  forward,  they  may  all  be 
included  in  a  single  incision  along  the  roof.  If  a  considerable  interval  of 
healthy  urethra  separates  them,  they  may  be  cut  at  the  same  sitting,  but  by 
different  operations,  the  deeper  one  being  cut  first.  The  flow  of  blood  forms 
no  material  impediment  to  cutting  the  second  stricture.  If  the  meatus  is 
to  be  cut,  it  may  be  included  in  the  first  incision  along  the  roof,  or,  per- 
haps better,  cut  along  the  floor  as  the  first  step  in  the  operation,  if  this 
has  not  already  been  attended  to  in  the  preliminary  examination  as  di- 
rected at  page  301.  No  ether  is  necessary  in  the  performance  of  this 
operation.  It  should  be  done  slowly,  for  accuracy  and  precision  are  es- 
sential factors  of  success.  Stretching  the  tissues  during  the  separation 


STRICTURE    OF    LARGE    CALIBRE.  307 

of  the  blades  generally  hurts  more  than  the  final  cut,  according  to  the 
assertion  of  most  patients. 

After  the  cutting  has  been  accomplished,  it  is  well  to  pass  a  bulbous 
sound  over  the  cut  region,  to  decide  whether  the  cutting  has  been  efficient 
and  has  thoroughly  relieved  the  constriction. 

If  this  is  found  not  to  be  the  case,  the  urethrotome  should  not  be  re- 
introduced.  The  second  cut  is  likely  to  pass  through  the  stricture  at  a 
different  point,  and  a  third  cut  to  take  still  another  route,  as  has  been 
proved  post-mortem  (Sands,  1.  c.,  p.  135).  Thus  the  stricture  becomes 
partly  cut  in  a  number  of  places,  its  outmost  circle  not  being  cut  through 
anywhere;  and  more  cutting  is  done  than  is  justified  by  the  end  in  view, 
since  each  cut  increases  the  possibility  of  pyzemic  complications.  The 
way  to  avoid  the  necessity  for  a  second  cut  is  to  make  the  first  one  de- 
liberately, to  locate  it  accurately,  and  to  make  it  deep  enough.  If  this  is 
not  done.  I  believe  it  to  be  wiser  to  postpone  the  second  operation  two  or 
three  weeks  until  the  first  cut  has  healed,  and  then  to  start  afresh,  as  if 
nothing  had  previously  been  done. 

It  remains  to  determine  how  deeply  to  cut  a  given  stricture  of  large 
calibre  in  the  pendulous  urethra.  This  cannot  be  absolutely  decided  by 
any  criterion  with  which  I  am  familiar.  Dr.  Otis  has  fortified  his  follow- 
ers with  a  scale  very  pleasing  in  its  apparent  accuracy,  based  upon  an 
alleged  constancy  of  relation  between  the  normal  size  of  the  urethra  and 
that  of  the  penis  in  repose;  yet  this  accurate  scale  (which  is  certainly 
only  approximate)  does  not  give  its  followers  the  satisfaction  of  doing  the 
whole  operation  at  a  single  cut.  In  all  the  operations  which  I  have  seen 
performed  by  surgeons,  and  in  most  of  those  recorded  in  medical  journals, 
the  urethrotome  is  introduced  twice  or  more  often  at  the  same  sitting;  and 
very  frequently  it  is  found,  after  some  days  or  weeks,  that  recontraction 
has  occurred,  and  the  stricture  has  to  be  cut  over  again.  I  have  personal 
knowledge  of  repetitions  in  the  cutting,  to  the  extent  of  four  times  at 
different  sittings,  having  been  done  on  one  and  the  same  individual,  by  a 
surgeon  than  whom  none  can  be  more  competent  in  this  operation,  and 
that  too  without  resulting  in  a  cure.  Consequently  it  is  rather  idle  to 
attempt  accuracy  by  measuring  so  uncertain  an  organ  as  the  penis,  even  if 
the  scale  possessed  the  accuracy  which  its  inventor  ascribes  to  it;  and  the 
question  remains:  What  rule,  if  any,  have  we  to  go  by? 

In  answer,  it  may  be  stated  as  a  general  proposition,  that  the  strict- 
ured  point  which  will  not  yield  to  dilatation  must  be  cut  so  as  to  be  con- 
siderably larger  than  the  normal  urethra  at  that  point;  and  that,  to  insure 
the  best  results,  a  single  cut  should  be  made — a  cut,  if  possible,  to  pass 
beyond  all  diseased  tissues  and  into  the  healthy  tissue. 

This  result  is  probably  often  attained  by  following  the  measurements 
of  Dr.  Otis,  since  his  estimation  of  the  size  of  the  urethra  is  extreme;  but 
even  his  measurements  will  not  suffice  in  some  cases  where  inodular  tis- 
sue has  involved  the  whole  substance  of  the  corpus  spongiosum,  while 
often  they  are  unnecessarily  high. 

The  best  guide  with  which  I  am  familiar  is  the  natural  size  of  the 
healthy  meatus — a  meatus  which  has  no  pockets  above  or  below,  or  out 
of  which  such  pockets  have  been  cut  with  the  bistoury,  so  that  the  meatus 
may  be  a  flat  slit,  and  not  a  round  point  at  the  apex  of  a  conical  glans  pe- 
nis. Furthermore,  it  must  be  remembered  that  the  strictured  area  is  not 
simply  to  be  restored  to  the  normal  calibre  of  the  urethra  at  that  point 
when  it  was  a  healthy,  elastic  canal;  but  it  must  be  cut  considerably  be- 
yond this  size,  both  to  insure  against  the  certain  amount  of  contraction 


308  THE    VENEREAL  DISEASES. 

which  necessarily  takes  place  at  the  angle  of  the  cut  as  it  heals,  and  the 
more  certainly  to  cut  through  the  outer  circle  of  fibres  at  the  constricted 
point. 

A  fair  rule  to  go  by  is  first  to  establish  the  fullest  size  to  which  the 
normal  ineatus  may  be  distended — the  normal  meatus  not  strictured  and 
without  pockets — and  to  cut  the  stricture,  after  having  screwed  up  the  ure- 
throtome  to  mark  not  less  than  two  sizes  (American,  three  or  four  sizes 
French)  higher  than  that  limit.  Should  the  meatus  be  strictured  congen- 
itally  or  by  disease,  the  surgeon's  judgment  must  guide  him  in  the  extent 
of  his  incision,  both  of  the  meatus  and  of  the  deeper-seated  stricture,  re- 
membering that  the  normal  meatus  of  the  full  average-sized  penis  in  the 
American  will  range  very  close  upon  20  American  scale  (30  P'rench).  In 
other  words,  a  conical  steel  instrument  of  size  20  will  pass,  by  its  own 
weight,  the  normal  meatus  (without  pockets)  in  the  average  American 
male  taken  at  random,  with  fair-sized  genitals,  or  certainly  may  be  passed 
with  a  little  coaxing,  putting  the  meatus  more  or  less  on  the  stretch, 
without  in  the  least  tearing  or  injuring  it.  A  penis  of  less  size  will  have 
a  more  moderate  urethra,  as  a  rule. 

It  has  been  found  by  experience,  as  Dr.  Otis  has  shown,  that  the 
breadth  of  the  knife-blade  does  not  count,  and  that  if  the  blades  of  the 
urethrotome  be  separated  to  20  and  the  cut  then  made,  the  strictured 
point  will  be  found  to  be  cut  not  above  size  20.  Therefore,  the  limits  of 
cutting  which  I  have  given  are  quite  moderate,  for  the  meatus  is  nor- 
mally the  smallest  part  of  the  canal,  and  an  incision  at  least  two  sizes 
larger,  lower  down,  is  not  extravagant,  since  the  cut  is  quite  certain  to 
lose  one  size  while  healing. 

If,  after  healing,  it  is  found  that  the  symptoms  persist,  and  the  re- 
siliency of  the  stricture  remaining  shows  that  the  outside  fibres  have  not 
been  cut  through,  then  another  operation  may  be  performed,  the  surgeon 
being  fortified  by  the  knowledge  gained  during  the  first  operation,  and  the 
cut  on  the  second  occasion  may  be  made  two,  or  even  three  (American) 
sizes  larger  than  before. 

I  believe  that  two  operations  are  safer  for  the  patient  than  one  per- 
formed at  random  or  extreme  on  the  start.  If  it  must  be  extreme — and 
possibly  some  exceptional  cases  require  it — the  extremity  should  be  pro- 
portioned to  the  necessity,  and  should  not  be  a  matter  of  routine.  If 
after  the  first  cutting  the  symptoms  disappear,  no  further  cutting  is  justi- 
fiable, even  although  the  urethrameter  or  bulbous  sound  should  detect 
that  the  point  cut  is  still  smaller  than  the  urethra  in  front  of  it  and  be- 
hind it.  The  occasion  for  interference  with  stricture  of  large  calibre  in 
the  pendulous  urethra  is  not  its  existence,  but  the  symptoms  it  produces. 
If  there  be  no  symptoms,  tight  spots  in  the  pendulous  urethra  of  large  cali- 
bre may  be  safely  disregarded. 

The  bleeding  after  internal  urethrotomy  is  very  variable.  A  deep  in- 
cision in  one  patient  may  be  attended  by  a  moderate  flow  of  blood,  while 
a  slight  cut  in  another  will  bring  on  profuse  haemorrhage.  In  a  given  pa- 
tient, however,  the  amount  of  haemorrhage  is  proportionate  to  the  number 
and  depth  of  the  cuts.  Generally,  pressure  will  arrest  the  bleeding.  It 
is  best  applied  with  the  fingers  placed  directly  over  the  urethra.  The 
blood  should  be  allowed  to  clot,  and  the  clot  that  forms  and  protrudes 
from  the  meatus  should  be  left  in  place  and  not  be  removed  with  the  fin- 
gers, for  this  only  allows  a  continuance  of  the  haemorrhage  and  necessi- 
tates the  formation  of  another  clot.  If  the  flow  of  blood  persists,  contin- 
uous pressure  from  without  may  be  tried  by  placing  a  piece  of  split  lead-  • 


STEICTUEE    OF   LAEGE    CALIBRE.  309 

pencil  along  the  urethra,  with  its  convexity  toward  the  skin,  and  securing 
it  in  place  with  adhesive  strips  and  a  narrow  bandage;  or,  what  is  better, 
if  at  hand,  the  instrument  especially  designed  for  the  purpose  by  Bates, 
of  Brooklyn,  may  be  employed.  It  is  constructed  on  the  same  principle 
as  Trendeleriburg's  tracheotomy  tube  and  Guyon's  lithotomy  tampon. 
This  instrument  is  simply  a  thin  rubber  tube  encircling  a  catheter,  and 
so  arranged  that  the»  outer  rubber  may  be  inflated  with  air  or  iced  water 
after  the  instrument  has  been  secured  in  place  so  as  to  pass  lower  than 
the  cut  point  (Fig.  34).  The  outer  tube  has  two  terminal  outlets,  b  and 


FIG.  34. 

c,  so  that  a  continuous  stream  of  iced  water  may  be  kept  passing  through 
it,  if  desired,  while  the  urine  may  be  drawn  through  the  catheter  by 
taking  out  the  plug,  a. 

Another  excellent  means  of  arresting  haemorrhage  is  by  injecting  the 
urethra  full  of  the  liquid  subsulphate  of  iron.  The  fluid  is  to  be  rapidly 
thrown  into  the  urethra,  a  drachm  is  usually  enough,  and  held  there  by  a 
thumb  and  finger  at  the  meatus  for  about  half  a  minute.  On  liberating  the 
meatus  a  discolored  watery  fluid  escapes,  but  no  red  blood  if  the  injection 
has  been  effective,  for  the  urethra  is  effectually  plugged  with  a  solid  black 
clot,  generally  quite  hard  enough  and  adherent  enough  to  stop  all  haemor- 
rhage. The  only  objection  to  this  process  is  that  it  tends  to  induce  sup- 
puration, and  sometimes  active  inflammation  of  the  urethra — perhaps  of  the 
whole  circumference  of  the  canal, — and  in  this  way  to  interfere  with  the 
subsequent  use  of  instruments  of  sufficient  size  to  maintain  the  cut  open 
until  it  has  healed  to  the  bottom. 

Sometimes  little  or  no  blood  escapes  at  the  moment  of  operation,  but 
later,  at  the  time  of  the  next  urination  or  during  erection  at  night,  hae- 
morrhage comes  on  which  sometimes  becomes  profuse.  The  same  means 
will  arrest  it  as  those  alluded  to  above. 

The  after-treatment  consists  in  th£  use  of  the  conical  steel  sound  at 
appropriate  intervals.  Twenty-four  hours  after  the  cutting,  a  full-sized 
sound — large  enough  to  put  the  meatus  fully  upon  the  stretch — may  be 
gently  introduced.  This  is  followed  by  haemorrhage,  sometimes  more  pro- 
fuse and  harder  to  arrest  than  that  which  occurred  at  the  moment  of  the 
operation;  but  it  yields  more  promptly,  as  a  rule,  and  generally  becomes 
arrested  spontaneously  after  a  few  moments.  After  another  interval  of 
forty-eight  hours,  the  same  full-sized  sound  may  be  introduced ;  or,  if  the 
urethra  be  generally  inflamed  so  that  the  size  causes  much  pain,  one  size 
lower  may  be  employed,  but  nothing  smaller.  Again,  in  forty-eight  hours, 
the  process  is  repeated.  The  next  interval  may  be  three  days,  and  the 
next  four.  After  this,  one  or  two  passages  of  the  sound,  at  intervals  of 
five  days,  often  terminate  the  case,  although  in  many  instances  a  much 
longer  time  is  necessary,  and  sometimes  one,  two,  or  even  more  sizes  in  the 
sound  are  lost,  owing  to  inflammatory  conditions  in  the  urethra  excited  by 
the  mechanical  violence  to  which  it  has  been  subjected.  The  cut  is  known 
to  be  healed  when  a  full-sized  instrument  may  be  passed  without  being 


310  THE    VENEREAL   DISEASES. 

followed  by  any  blood;  but  even  after  this  it  is  wise  to  keep  up  the  use 
of  a  full-sized  sound,  at  longer  intervals,  for  a  time. 

If  now  the  symptoms  have  disappeared,  the  sound  may  be  laid  aside, 
and  the  patient  is  and  remains  well,  although  manipulation  with  the 
urethrameter  may  still  detect  that  the  point  cut  is  smaller  than  other 
parts  of  the  urethra.  If  the  symptoms  persist  and  the  stricture  recon- 
tracts,  it  may  be  cut  again  as  before,  but  to  a  greater  extent,  as  already 
described  above. 

These  remarks,  I  must  again  repeat,  apply  to  strictures  in  the  pendu- 
lous urethra. 

The  complications  attending  this  operation  besides  haemorrhage,  which 
can  always  be  arrested  in  the  pendulous  urethra,  are  those  inherent  to 
most  operations  upon  the  canal,  and  due  often  as  much  to  the  after-treat- 
ment by  instruments  as  to  the  cutting  operation.  They  are  urethral  fever 
from  shock,  epididymitis,  cystitis,  possibly  prostatic  or  peri-urethral  ab- 
scess, sometimes  yielding  fistula,  occasionally  pyaemia  and  surgical  kid- 
ney. Another  complication,  not  very  uncommon  where  the  cut  has  been 
deep,  is  the  formation  of  new  modular  tissue  in  the  corpus  spongiosum, 
causing  painful  erection  and  chordee.  Some  writers  have  reported  that 
the  latter  condition  may  remain  more  than  a  year;  painful  erections  often 
persist  for  many  months. 

All  these  complications  call  for  treatment  when  they  arise,  and  many 
of  them  demand  a  cessation  in  the  employment  of  instruments  to  keep 
the  cut  open.  Thus,  the  latter  is  allowed  to  close,  and  much  of  the  good 
which  might  have  been  attained  by  the  operation  is  lost.  One  of  the 
best  means  of  avoiding  complications  after  urethrotomy  is  to  keep  the 
patient  quiet  upon  his  back  for  several  days  after  he  has  been  cut,  giv- 
ing him  plenty  of  bland  diluents  to  drink,  and  enough  bromide  or  opium, 
if  need  be,  to  keep  down  erections.  The  ingenious  device  of  surround- 
ing the  penis  with  a  coil  of  rubber-tubing,  through  which  iced  water  is 
made  to  flow  continuously,  has  proved,  in  my  hands,  rather  a  source  of 
erections  than  a  restraint  upon  them.  Injections  are  not  desirable  in  the 
after-treatment  of  urethrotomy,  and  the  balsams  are  useless.  Laxatives 
are  of  service  while  the  patient  is  in  bed. 


CHAPTER  V. 

STRICTURE  OF  SMALL  CALIBRE. 

Symptoms  of  Tight  Organic  Stricture ;  Diagnosis. — Expedients  for  Threading  fine  Stric- 
tures.— Treatment  of  Stricture  of  Small  Calibre. — Continuous  Dilatation. — Inter- 
nal Urethrotomy  of  the  Deep  Urethra. — Divulsion. — Perineal  Section;  with  a 
Ghiide  ;  without  a  Guide. — Urethral  Fever  and  its  Treatment. 

ORGANIC  stricture  of  small  calibre  of  any  size,  from  10,  American 
scale,  down  to  a  constriction  through  which  nothing  can  be  passed,  is  the 
most  important  malady  of  the  urethra  with  which  the  surgeon  has  to  con- 
tend. Its  causes  are  gonorrhoea  and  mechanical  or  (rarely)  chemical 
violence;  its  origin  may  be  congenital;  at  the  meatus,  the  cicatrization 
of  ulcers  is  a  not  infrequent  cause. 

The  seat  of  election  of  this  stricture,  as  shown  by  all  the  statistics 
with  which  I  am  familiar — which  have  been  collected  in  the  dead-house, 
as  well  as  by  the  daily  experience  of  the  great  majority  of  capable  clini- 
cal observers — is  in  the  deep  urethra,  at  the  bulbo-membranous  junction 
or  thereabouts,  when  due  to  gonorrhoea;  a  little  farther  back,  even  well 
in  the  membranous  urethra,  after  such  common  traumatisms  as  bruising 
injuries  of  the  crotch.  It  may  be  found  also  congenitally,  or  as  a  result 
of  a  cicatrix  at  the  meatus,  or  anywhere  along  the  pendulous  urethra, 
due  to  injury  or  to  gonorrhoea,  when  there  has  been  much  chordee,  espe- 
cially if  the  chordee  has  been  broken.  In  the  latter  case,  the  stricture  is 
due  to  the  mechanical  rupture  of  the  stiffened  and  inflamed  corpus  spon- 
giosum  more  than  to  the  gonorrhoea  pure  and  simple.  Much  that  has 
been  said  in  the  last  chapter,  in  a  general  way,  concerning  stricture  of 
large  calibre,  applies  equally  well  here;  but  some  especial  points  in  re- 
gard to  tight  organic  strictures  call  for  a  separate  description. 


SYMPTOMS    OF   TIGHT    ORGANIC    STRICTURE. 

The  most  common  symptom  of  tight  organic  stricture  is  a  diminution 
in  the  size  of  the  stream  of  urine.  The  flow  may  be  projected  in  full 
force,  and  the  stream  be  as  smooth  as  possible,  perhaps  bright  and  clear; 
but  it  is  a  mechanical  impossibility  that  it  should  be  large.  The  patient 
may  assert,  as  he  often  does,  that  he  never  in  his  life  passed  a  larger 
stream,  but  such  assertions  are  of  no  value.  Generally  the  stream  is  not 
smooth,  but  flattened,  or  variously  distorted.  One  stream  may  flow  away 
with  some  force,  while  another,  starting  below  it  without  force,  dribbles 
to  the  ground,  or  takes  a  different  direction,  or  perhaps  twists  itself 
partly  around  the  other.  Again,  when  the  stricture  is  quite  tight,  the 
flow  is  apt  to  commence  painfully  in  drops,  and  only  to  reach  the  propor- 
tions of  a  continuous  stream  after  the  lapse  of  some  time,  and  after  con- 
siderable effort  on  the  part  of  the  patient.  From  catching  cold,  or  by 


312  THE    VENEREAL    DISEASES. 

the  effect  of  local  spasm  from  other  cause,  the  constricted  point  may  be- 
come actually  occluded,  so  that  retention  comes  on.  After  this  has  been 
relieved  in  one  way  or  another,  the  patient  again  urinates  with  more  or 
.  less  facility,  until  he  is  overtaken  by  another  retention,  by  cystitis,  or  by 
some  other  symptom,  which  leads  him  to  seek  advice. 

The  next  symptom  in  frequency  is  gleet.  Gleet,  more  or  less  puru- 
lent, is  found  in  nearly  all  cases  of  tight  stricture,  but  its  presence  is  not 
necessary.  I  have  known  a  stricture,  traumatic  in  origin,  almost  impas- 
sable to  a  whalebone  bougie,  and  yet  existing  for  years  without  the  least 
show  of  gleet. 

Irritability  of  the  bladder  is  a  very  common  symptom  caused  by  tight 
stricture.  The  cystitis,  which  comes  on  gradually,  is  mainly  confined  to 
the  neck  of  the  bladder  ;  it  is  very  mild  in  character  at  first,  but  goes  on 
increasing,  so  that  in  many  cases  of  old  tight  stricture  the  bladder  symp- 
toms alone  are  those  for  which  the  patient  consults  a  surgeon,  and  for 
which  he  demands  relief,  perhaps  by  medicine,  ignoring  the  cause  in  the 
urethra.  The  urine,  in  these  cases,  is  more  or  less  charged  with  pus. 
Partial  relapsing  chronic  epididymitis  is  another  symptom  of  stricture  far 
from  uncommon,  and  to  these  may  be  added  perineal  fistula  following  ab- 
scess, infiltration  of  urine,  and  a  long  list  of  reflex  phenomena,  already 
alluded  to  in  the  chapter  on  stricture  of  large  calibre;  urethral  neuralgia, 
sciatica,  pains,  paralysis,  spasm,  etc.,  and  certain  remote  symptoms 
such  as  hydrocele,  stone  in  the  bladder,  sterility,  etc.  Finally,  the 
natural  ultimate  result  of  tight  stricture  is  general  chronic  inflammation 
of  the  bladder,  attended  by  thickening  of  the  walls  of  the  viscus,  some- 
times concentric  hypertrophy  (thickening  of  the  walls,  with  permanent 
diminution  of  the  cavity),  dilatation  of  the  ureters,  pyelitis,  interstitial 

girenchymatous  nephritis,  uraemia,  and  death.     Many  a  death  ascribed  to 
right's  disease  is  in  reality  due  to  kidney  changes,  brought  on  by  long- 
standing tight  stricture  of  the  deep  urethra. 


DIAGNOSIS   OF   STRICTURE   OF   SMALL   CALIBRE. 

Tight  stricture  at  the  meatus  may  be  seen.  Along  the  pendulous 
urethra  it  may  often  be  felt  from  the  outside,  being  usually  more  or  less 
inodular,  composed  of  a  new  deposit  of  fibroid  material  similar  to  the  tis- 
sue of  the  cicatrix  after  a  burn.  An  accurate  diagnosis,  however,  may  be 
made  from  within  the  urethra  by  the  use  of  instruments  for  exploring  the 
canal. 

Nothing  more  need  be  added  to  what  has  already  been  said  in  the  last 
chapter  concerning  the  possibility  of  confounding  spasm  of  the  deep  urethra 
with  true  organic  spasm.  If  the  precaution  be  taken  to  commence  an  ure- 
thral examination  with  a  large-sized  blunt  (not  conical)  steel  instrument 
thoroughly  warmed,  and  to  proceed  as  directed  in  the  section  on  the  diag- 
nosis of  spasmodic  stricture,  I  think  that  an  error  will  become  practically 
impossible.  In  any  doubtful  case  it  is  wise  to  bring  the  meatus  up  to  its 
full  normal  size,  as  laid  down  in  the  last  chapter,  before  commencing  the 
exploration,  or  it  may  not  be  possible  to  use  a  large  enough  blunt  steel 
instrument  to  decide  the  question  positively. 

Commencing,  then,  with  a  large  blunt  instrument,  and  working  down 
to  smaller  sizes,  it  will  sometimes  turn  out  that  the  tight  organic  stricture 
does  not  exist  at  all.  A  surgeon  may  declare  that  no  instrument  will  pass 
because  he  has  used  a  fine  whalebone  to  commence  with,  and,  having  caught 


STRICTUEE    OF    SMALL    CALIBRE. 


313 


this  in  some  follicle,  has  been  unable  to  reach  the  bladder;  or,  he  may  have 
passed  a  small  instrument  into  the  bladder,  and,  finding  this  held  somewhat 
by  the  urethra  on  its  way  out,  he  decides  that  there  is  tight  organic  stric- 
ture. 

It  has  happened  to  me  in  my  clinique,  at  Bellevue  Hospital,  to  have 
a  patient  brought  in  under  these  circumstances — a  patient  whom 
I  had  not  before  seen — to  be  operated  on  as  a  case  of  tight  organ- 
ic stricture.  Commencing  the  examination  with  a  full-sized,  blunt 
steel  sound,  I  have  been  able  to  pass  the  latter  readily  by  its  own 
weight  into  the  bladder.  This  is  by  no  means  uncommon  in  private 
practice.  I  have  encountered  it  frequently;  and,  in  many  of  these 
cases,  the  spasm  of  the  muscles  of  the  deep  urethra  yields  to  the 
blunt  instrument  without  any  previous  cutting  of  strictures  at  the 
meatus  or  elsewhere  in  the  pendulous  urethra,  and  the  spasm  itself 
is  due  to  a  cause  other  than  an  irritation  in  the  forward  parts  of  the 
urethra. 

Passing  down,  then,  after  failure  of  the  foregoing  manoeuvre, 
from  large  to  small  blunt  steel  sounds,  of  course  skipping  several 
sizes  at  a  time,  an  obstacle  is  encountered  invariably  at  the  same 
depth,  at  the  seat  of  stricture.  Locating  it  positively  in  this  way, 
after  size  10,  American  (blunt),  has  been  tried  in  vain,  an  effort  to 
reach  the  bladder  may  be  made  with  a  small,  soft,  black  conical 
bougie,  sharp-pointed,  not  olivary  (Fig.  35).  Several  of  these  may 
be  tried,  and,  at  last,  a  Benas  bougie,  which  is  simply  a  thread  of 
whalebone,  covered  with  a  kind  of  black  varnish. 

If  any  instrument  so  far  tried  passes  the  stricture,  the  amount  of 
ease  with  which  it  glides  through  the  tight  spot  should  be  esti- 
mated, the  instrument  immediately  withdrawn,  and,  unless  there 
be  some  special  reason  to  the  contrary,  the  patient  should  be  let 
alone  to  see  what  effect  will  follow  the  first  instrumentation.  If 
urethral  fever  follows,  and  especially  if  the  patient  has  albumen 
in  his  urine,  all  subsequent  explorations  must  be  made  with  special 
care,  and  possibly  also  with  the  assistance  of  certain  medical  aids 
for  the  prevention  of  chill,  which  I  shall  mention  shortly. 

If  none  of  the  instruments  thus  far  tried  will  pass,  a  very  valua- 
ble instrument  still  remains — the  filiform  whalebone  bougie,  with 
the  point  twisted  into  spiral,  or  bent  so  as  to  be  thrown  out  of  the 
axis  of  the  shaft  of  the  instrument,  as  shown  in  Fig.  36. 

A  small  syringeful  of  warmed  oil  is  first  thrown  into  the  ure- 
thra, and  then  the  surgeon  feels  the  anterior  face  of  the  stricture 
with  the  twisted  end  of  one  of  these  fine  whalebones.  By  advan- 
cing the  instrument  during  rotation,  with  the  ure- 
thra made  tense  by  pulling  upon  the  penis,  the  tip 
of  the  filiform  bougie  is  presented  at  different 
points  upon  the  face  of  the  stricture,  and  finally, 
in  a  skilled  hand,  is  quite  certain  to  find  the  orifice 
of  the  stricture  and  to  enter  it.  Once  entered,  the 
rigidity  of  the  whalebone  comes  into  play,  and  the 
instrument  promptly  passes  on  and  enters  the  blad- 
der. It  is  rare,  indeed,  to  encounter  a  stricture  into 
FIG.  36.  which  one  of  these  slender  little  instruments  can-  FIG.  36. 

not  be  made  to  pass ;  nearly  all  the  so-called  im- 
permeable strictures  yield  to  them.     The  main  difficulty  in  their  employ- 
ment is  the  facility  with  which  the  point  becomes  entrapped  in  the  mouths 


314  THE    VENEREAL    DISEASES. 

of  dilated  follicles,  or  of  a  false  passage,  should  one  exist.  This  defect  may 
in  a  measure  be  overcome  by  the  well-known  device  of  crowding  the  ure- 
thra full  of  these  fine  threads  of  whalebone,  and  then  pushing  upon  them 
alternately  until  the  one  which  presents  at  the  mouth  of  the  stricture 
passes  on  into  the  bladder. 

Another  expedient,  which  I  should  feel  inclined  to  try  in  case  of  failure 
to  pass  a  tight  stricture,  is  that  recommended  by  Dr.  Hadden,  in  the  New 
York  Medical  Record  of  1877,  July  7th,  p.  421.  I  have  not  tried  it,  because 
I  have  not  failed  to  pass  a  stricture  since  I  read  the  article.  The  expedient 
is  simple  and  plausible.  It  consists  in  carrying  iced  water  through  the 
long  nozzle  of  a  syringe,  directly  against  the  anterior  face  of  the  stricture, 
for  a  few  moments,  after  which,  Dr.  Hadden  says  that  in  his  hands  a 
stricture  became  permeable,  which  was  not  so  previously.  Doubtless  the 
cold  sound  (p.  269)  would  serve  the  same  purpose,  and  it  would  be  easier 
to  manage  ;  and,  theoretically,  I  am  not  certain  that  very  hot  water,  car- 
ried through  the  cold  sound,  would  not  answer  the  purpose  (of  relaxing 
spasm)  still  better  than  iced  water. 

Finally,  if  no  instrument  can  be  passed,  ether  may  be  administered, 
and  the  attempt  renewed.  A  filiform  bougie,  or  even  a  large  instru- 
ment, may  pass  under  ether  when  all  attempts  without  an  anaesthetic  have 
failed. 

By  these  means  a  stricture  may  be  located,  its  permeability  ascertained, 
and  its  calibre  estimated. 

TREATMENT    OF   STRICTURE    OF   SMALL   CALIBRE. 

As  has  been  already  stated,  tight  strictures  at  and  near  the  meatus 
must  be  cut.  Strictures  of  small  calibre  are  quite  rare  in  the  pendulous 
urethra.  When  they  do  occur,  it  is  probably  better,  as  a  rule,  to  cut 
them,  since  they  are  quite  certain  in  the  long  run  to  prove  resilient,  and 
require  cutting,  perhaps,  after  much  time  has  been  lost  in  attempts  at 
dilatation.  If  they  prove  too  narrow  to  receive  the  dilating  urethrotome, 
their  calibre  may  be  safely  raised  in  a  few  days,  by  what  is  known  as  con- 
tinuous dilatation  (described  below),  and  then,  as  soon  as  the  urethrotome 
will  pass  comfortably,  they  may  be  cut. 

For  all  strictures  of  the  deep  urethra,  dilatation  should  be  the  rule,  and 
all  operative  measures  the  exception,  for  the  double  reason  already  stated: 
1.  An  operation  means  danger  to  the  patient,  and  such  a  risk  his  physical 
condition  does  not  usually  warrant;  2.  After  cutting  internally  or  exter- 
nally, and  after  divulsion,  a  radical  cure  is  not  attained  in  most  instances 
— only  relief  as  a  rule,  which  is  made  effective  by  a  continuance  of  dilata- 
tion, at  more  or  less  prolonged  intervals,  for  an  indefinite  period. 

Dilatation,  therefore,  is  to  be  employed  whenever  practicable.  This  is 
done  much  after  the  manner  advised  in  the  case  of  stricture  of  large  cali- 
bre, with  the  exception  that,  where  soft  instruments  are  used,  the  inter- 
vals may  be  considerably  shortened.  Practically,  however,  the  rule  is  the 
same.  When  the  effect  of  one  dilatation  is  at  its  height,  another  larger 
instrument  should  be  gently  introduced  and  immediately  withdrawn. 
With  very  fine  instruments,  one  day  is  a  long  enough  interval  to  be  al- 
lowed to  pass  after  the  first  sitting  ;  then  the  interval  may  be  raised  to 
two,  then  to  three  and  four  days,  with  advantage.  As  soon  as  size  10 
American  is  reached,  soft  instruments  may  be  abandoned  and  the  dilata- 
tion continued  with  conical  steel  sounds,  as  in  the  case  of  stricture  of 
large  calibre. 


STRICTURE    OF   SMALL   CALIBRE.  315 

When,  in  the  case  of  a  very  tight  stricture,  a  fine  whalebone  has  been 
only  introduced  after  many  days  of  patient  trial,  and  especially  if  there 
be  actual  or  impending  retention,  the  surgeon's  course  should  depend 
in  a  measure  upon  the  character  of  the  stricture,  as  well  as  the  character 
of  the  patient.  If  the  stricture  be  inodular,  complicated  with  perineal 
fistula,  or  very  hard  and  of  traumatic  origin;  or  attended  by  perineal  ab- 
scess; or  (above  all)  by  infiltration  of  urine;  or  if  the  patient  be  hard  to 
manage,  having  been  partly  cured  before  and  then  allowed  himself  to 
relapse;  or  if  he  be  urgently  pressed  for  time,  or  subject  to  repeated  and 
prostrating  attacks  of  urethral  fever  (his  kidneys  being  presumably  sound) 
— under  any  of  these  circumstances  perineal  section  upon  a  guide  is  called 
for,  and  should  be  performed  at  once  or  within  twenty-four  hours.  The 
guide  may  be  tied  in  the  urethra  and  left  there  until  the  operation. 

If  the  case  be  not  urgent  on  any  of  the  above  grounds,  while  it  has 
been  quite  difficult  to  pass  the  stricture  with  the  filiform  bougie,  the  mild 
and  very  efficient  expedient  of  continuous  dilatation  may  be  used. 

Continuous  dilatation  is  the  action  exerted  upon  a  stricture  by 
the  constant  presence  of  an  instrument  passed  through  it.  The  whale- 
bone, once  inserted,  is  simply  to  be  retained  in  place  by  a  piece  of  heavy 
silk  tied  tightly  around  it  near  the  meatus.  The  two  ends  of  the  silk  are 
then  tied  together  so  that  the  knot  shall  lie  upon  the  frenum  just  at  the 
curve  of  the  corona  glandis,  and  then  the  separate  ends  are  carried  around 
on  either  side  under  the  corona,  and  tied  with  moderate  tightness  upon  the 
dorsum. 

In  this  condition  the  patient  is  sent  home  and  told  to  keep  quietly 
about  the  house.  In  twenty-four  hours  the  whalebone  may  be  removed 
and  one  several  sizes  larger  introduced  with  ease.  This  is  in  its  turn  tied 
in.  The  patient  urinates  easily  alongside  of  the  instrument.  The  con- 
tinuous pressure  causes,  first,  muscular  action,  spasm,  and  the  bougie  is 
grasped,  then  relaxation  of  spasm,  then  inflammatory  swelling,  then 
absorption,  and  usually  suppuration.  The  second  instrument  may  be  left 
in  two  days  or  more.  In  this  way,  in  a  week  most  strictures  (if  commenced 
with  very  small)  may  be  raised  a  dozen  sizes.  The  larger  the  calibre  of 
the  stricture,  the  less  promptly,  as  a  rule,  does  continuous  dilatation  af- 
fect it.  After  the  stricture  has  reached  a  certain  size,  treatment  by  ordi- 
nary dilatation  may  be  commenced;  but  the  intervals  must  be  rather  short 
at  first,  since  a  stricture  promptly  raised  to  a  large  size  by  this  method 
very  promptly  falls  back  again  if  let  alone. 

There  are  some  cases  of  tight  stricture  in  which  one  may  be  content 
with  simply  passing  a  filiform  instrument  and  not  tying  it  in,  trusting 
that  on  the  following  day  a  larger  size  may  enter,  as  in  ordinary  treat- 
ment by  dilatation. 

Finally,  there  are  cases  not  quite  desperate  enough  to  justify  exter- 
nal urethrotomy,  not  able  to  give  the  time  to  ordinary  dilatation  (al- 
though it  does  not  call  for  a  day  in  the  house,  much  less  in  bed),  and  yet 
urgent  enough  to  justify  prompt  measures  which  shall  afford  speedy  relief. 
For  this  class  of  cases  two  operations  remain — internal  urethrotomy  and 
divulsion. 

Internal  urethrotomy  of  the  deep  urethra,  in  my  opinion,  is  not 
so  good  an  operation  as  divulsion.  The  cases  in  which  I  have  practised 
it  have  given  me  but  little  satisfaction.  The  bleeding  is  apt  to  be  trouble- 
some, and  much  harder  to  arrest,  I  have  found,  than  haemorrhage  from  the 
pendulous  urethra.  I  have  never  seen  a  radical  cure  effected  by  internal 
urethrotomy  in  the  deep  urethra;  many  deaths  due  to  the  operation  are  re- 


316 


THE   VENEREAL   DISEASES. 


corded  in  the  journals,  and  many  more  have  not  been  recorded.  In  any 
case  the  operation  is  only  an  adjuvant  to  dilatation;  it  prepares  the  way. 
I  do  not  by  any  means  condemn  the  operation;  but  I  do  not  like  it,  and  I 
think  divulsion  better. 

If  urethrotomy  is  to  be  performed  internally,  probably  Maisonneuve's 
modified  instrument  is  as  good  as  another  for  the  purpose.  The  grooved 
staff  A  (Fig.  37)  screws  upon  a  soft  conducting  bougie,  b,  d,  or  is  tunnelled 
at  the  end  to  slip  over  the  whalebone  guide,  and 
a  rather  small  knife  may  be  used,  B,  a,  prefera- 
bly with  a  blunted  top  to  shield  the  healthy 
mucous  membrane  as  the  knife  is  thrust  along 
the  groove  toward  the  stricture.  Without  this 
shield,  and  sometimes  with  it,  the  healthy  mu- 
cous membrane  all  along  the  urethra  is  more  or 
less  cut  on  the  roof  or  floor  of  the  canal,  as  the 
case  may  be,  as  the  knife  is  passing  down  to- 
ward the  stricture. 

The  after-treatment  and  means  of  arresting 
haemorrhage  are  much  the  same  in  this  operation 
as  after  internal  urethrotomy  of  the  pendulous 
urethra  (page  305). 

DIVULSION. 

This  operation  is  not  at  the  present  day  held 
in  favor  to  such  an  extent  as  internal  urethrot- 
omy, probably  because  it  seems  to  be  a  rougher 
procedure.  It  has  the  great  advantage,  how- 
ever, of  calling  for  less  after-treatment  by  instru- 
ments in  the  urethra,  the  haemorrhage  is  much 
lighter,  and  the  effect  equally  lasting.  The 
danger  is  certainly  no  greater  in  this  operation 
than  it  is  in  internal  urethrotomy,  and,  for  the 
deep  urethra,  I  consider  it  the  preferable  opera- 
tion. 

The  best  instrument  with  which  to  divulse 
a  stricture  I  believe  to  be  Thompson's  tunnelled 
divulsor,  as  made  in  America,  capable  of  being 
screwed  up  to  size  21,  American  scale.  Fig.  38, 
a,  represents  the  instrument.  By  turning  the 
handle  the  blades  may  be  separated,  b,  the 
amount  of  separation  being  registered  upon  an 
index  in  the  handle.  The  instrument  is  to  be 
used  as  follows: 

The  depth  of  the  front  face  of  the  stricture 
from  the  meatus  is  at  first  accurately  ascertained. 
Then  a  filiform  whalebone  bougie,  twenty  inches 
long,  must  be  passed  through  the  stricture  until 
its  distal  extremity  reaches  the  meatus,  the 
other  end  lying  coiled  up  in  the  bladder  beyond 
the  stricture.  The  urethra  now  being  injected  full  of  warmed  oil  and  the 
divulsor  being  well  anointed  with  vaseline,  the  tunnel  is  threaded  over  the 
whalebone  guide,  and,  while  the  tip  of  the  guide  and  the  end  of  the  penis 
are  held  tense  with  one  hand,  with  the  other  the  divulsor  is  slowly  to  be 


FIG.  37. 


STRICTURE    OF   SMALL   CALIBRE. 


317 


pushed  along  over  the  guide,  through  the  stricture  and  into  the  bladder, 
until  its  point  of  greatest  dilatability  lies  at  the  centre  of  the  stricture. 
The  outside  of  the  divulsor  is  marked  in  inches  to  facilitate  this  step  in 
the  operation. 

It  is  necessary  to  take  every  precaution,  in  guiding  the  divulsor  into 
the  bladder,  not  to  let  it  double  up  the  guide  in  front  of  itself.  To  guard 
against  this,  during  the  whole  time  that  the  point  of  the  divulsor  is  trav- 
elling the  curved  part  of  the  urethra  the  guide  should 
be  pulled  upon  very  gently,  so  that,  as  the  divulsor 
slips  in,  the  guide  is  being  steadily  pulled  out.  If 
too  much  of  the  guide  is  used  in  this  way  at  any  time, 
the  divulsor  being  left  in  place,  the  guide  may  be  again 
pushed  forward  through  the  stricture  and  the  tunnel 
until  all  its  excess  is  again  coiled  up  in  the  bladder, 
and  then,  by  coaxing  and  gentle  manipulation  of  the 
divulsor  while  the  guide  is  being  again  withdrawn, 
the  steel  instrument  is  carried  safely  into  the  bladder, 
guided  by  the  whalebone. 

When  the  divulsor  is  in  place,  the  guide  should  be 
entirely  withdrawn  and  the  process  of  divulsion  im- 
mediately commenced.  The  handle  of  the'divulsor 
may  be  turned  slowly  or  rapidly.  If  slowly,  it  pains, 
I  think,  more  in  the  total  amount;  but  some  patients 
prefer  it.  Occasionally  a  strong-minded  man  prefers 
to  screw  up  the  divulsor  himself.  Generally  it  is 
better  to  screw  up  the  handle  rapidly,  and  save  time 
•while  the  patient's  mind  is  made  up  to  endure  the 
pain,  for  it  is  never  necessary  to  use  an  anaesthetic. 

The  handle  is  to  be  turned  until  such  a  grade  of 
dilatation  has  been  reached  as  shall  have  been  pre- 
viously determined  upon,  or  until  blood  begins  to  flow 
rather  freely  from  the  meatus,  indicating  that  the  mor- 
bid tissue  has  been  divulsed — torn  through.  The 
stricture-tissue  is  brittle,  and,  although  tough,  it  tears 
more  easily  than  the  sound  tissue,  the  elasticity  of 
which  allows  it  to  escape  any  considerable  injury. 
Thus,  the  process  of  divulsion  effects  about  the  same  result  as  internal 
urethrotorny,  with  the  difference  that  the  torn  tissue  bleeds  less  than  a 
similar  wound  made  with  the  knife  would,  and  has  very  little  tendency 
to  heal  up  immediately;  both  of  which  results  in  my  opinion  are  very 
desirable,  since  they  do  away  with  the  necessity  for  a  considerable  amount 
of  after-treatment  which  might  otherwise  be  required. 

As  the  divulsor  is  being  unscrewed  preparatory  to  its  removal,  its 
handle  should  be  gradually  depressed  between  the  thighs,  and  its  point 
pushed  forward  into  the  bladder  until  the  blades  meet,  when  they  may  be 
safely  withdrawn.  Without  the  exercise  of  this  precaution,  it  sometimes 
happens  that  the  closing  blades  catch  a  portion  of  mucous  membrane — 
either  the  ragged,  torn  edge  of  the  stricture,  or  a  fold  of  membrane  lower 
down  the  urethra,  and  pinch  it  so  tightly  that  the  instrument  cannot 
be  disengaged  by  again  screwing  it  up.  The  little  piece  of  mucous 
membrane  in  such  a  case  must,  of  necessity,  be  torn  away  before  the 
instrument  can  be  extricated.  This  accident  I  have  seen  happen  a 
number  of  times.  I  have  never  observed  that  any  evil  effect  followed; 
but  it  certainly  does  no  good,  and  makes  the  urethra  much  more  sore  and 


PIG.  38. 


318  THE    VENEREAL    DISEASES. 

unable  to  receive  an  instrument  again  so  soon  as  it  would  otherwise  have 
done.  It  is  so  easy  to  avoid  this  accident  by  the  little  manoeuvre  I  have 
referred  to,  that  it  need  rarely,  if  ever,  happen.  It  is  certainly 
better  to  avoid  it. 

After  the  divulsor  has  been  withdrawn,  the  bleeding  invariably, 
stops  promptly,  and  no  other  instrument  should  be  passed  into 
the  urethra.  The  patient  is  simply  put  to  bed,  and  told  to  remain 
there  from  twenty-four  to  thirty-six  hours,  after  which  he  may  get 
up  and  go  about  his  business.  If  he  has  no  chill  within  this  period, 
the  probability  is  that  all  danger  is  over.  If  he  has  a  chill,  he  must 
be  kept  longer  in  bed,  and  his  temperature  watched  to  see  whether 
the  chill  signifies  anything  more  than  ordinary  urethral  fever. 

The  question  of  urethral  fever,  and  of  the  after-treatment  of  all 
operations  upon  the  urethra,  will  be  discussed  presently. 

After  divulsion  no  instrument  should  be  passed  into  the  urethra 
until  the  lapse  of  from  five  to  eight  days.  The  torn  tissues  do  not 
tend  to  unite,  as  a  cut  does.  The  tear  suppurates,  and  it  is  better 
not  to  attempt  to  pass  an  instrument  over  it  until  granulations 
have  formed  and  the  inflammatory  barrier  has  been  erected  by 
nature  under  the  raw  surface.  Therefore,  first  upon  the  sixth  or 
seventh  day,  an  instrument  is  to  be  used.  Meantime  the  patient 
usually  urinates  freely,  and  enough  suppuration  has  come  on  to 
occasion  quite  a  purulent  gleet.  The  first  instrument  passed  should 
be  an  olivary,  conical,  soft  French  black  bougie,  the  olive  being 
upon  a  slender  neck,  so  that  when  touched  with  the  finger  the  neck 
promptly  bends  (Fig.  39).  Such  an  olive  will  slip  over  the  angle  at 
the  bottom  of  the  tear  in  the  stricture,  while  a  conical  point  or  a  steel 
instrument  might  readily  catch  in  it,  start  a  quantity  of  fresh  blood, 
and  make  a  false  passage.  The  shaft  of  the  olivary  bougie  should 
be  as  large  as  the  calibre  of  the  meatus  will  readily  allow  to  pass. 

This  instrument,  then,  well  anointed  with  vaseline,  is  slowly  and 
steadily  pushed  downward  into  the  urethra,  and  if  the  divulsion 
has  been  thorough  it  should  go  smoothly  forward  into  the  bladder, 
and  its  extraction  should  be  followed  by  the  appearance  of  very 
little  blood.  No  other  instrument  need  be  used  for  forty-eight 
hours.  Then  the  same  soft  bougie  may  be  passed,  followed  by  a 
conical  steel  sound  of  larger  size,  and  from  this  time  onward,  on 
every  fourth  or  fifth  day,  steel  instruments  of  increasing  sizes  should 
be  introduced,  until  the  largest  size  the  healthy  meatus  will  take 
passes  smoothly  into  the  bladder  without  being  followed  by  the 
appearance  of  blood  on  its  withdrawal. 

Now  the  stricture  may  be  called  cured,  so  far  as  any  operation 
will  cure  it,  and  the  patient  should  be  instructed  in  the  use  of  a 
conical  steel  sound,  which  he  should  be  ordered  to  pass  for  himself 
once  a  week,  on  pain  of  a  return  of  his  stricture.  After  a  time 
the  intervals  may  be  lengthened,  and  if  recontraction  does  not 
occur,  the  sound  may  be  finally  abandoned;  but  there  is  no  cer- 
tainty how  much  time  must  pass  before  this  result  is  reached,  or, 
indeed,  that  it  ever  will  be  reached.  I  have  known  patients,  whose  inter- 
vals, after  years  of  use  of  the  sound,  had  reached  three  and  four  months, 
and  in  whom  no  symptoms  of  stricture  existed,  and  no  evidence  furnished 
by  the  sound  they  were  using,  yet  who,  from  motives  of  ordinary  prudence, 
preferred  to  pass  the  sound  three  or  four  times  during  the  year,  and  in- 
tended to  continue  doing  so  during  the  remainder  of  their  lives. 


STEICTUEE    OF   SMALL   CALIBRE. 


319 


The  possible  complications  following  divulsion  are  the  same  as  those 
liable  to  be  encountered  after  urethrotomy.  Haemorrhage,  however,  is 
very  rare,  and  all  the  other  complications  less  common,  because  there  is 
less  occasion  for  using  instruments  in  the  urethra;  and  these  instruments, 
acting  upon  an  inflamed  canal,  are  often  more  at  fault  in  lighting 
up  complications  than  the  operation  itself. 

PEEINEAL    SECTION. 

This  operation  is  imperatively  called  for  by  tight  organic 
stricture  deeply  situated  in  the  urethra,  under  certain  circum- 
stances, such  as  infiltration  of  urine,  perineal  abscess,  numerous 
fistulje,  and  where  the  stricture  is  impermeable  to  an  instrument 
passed  from  the  meatus. 

The  latter  contingency  alone  does  not  necessarily  demand 
external  urethrotomy.  It  is  often  better  in  such  a  case  to  as- 
pirate the  bladder  with  a  fine,  perforated  needle  above  the  sym- 
physis  pubis,  once  or  twice  if  need  be,  and  then  to  try  the  urethra 
again  with  a  whalebone  guide.  Some  traumatic  strictures  also 
of  the  deep  urethra  are  excessively  tough  and  resilient,  so  that 
they  will  not  yield  to  the  divulsor,  and  do  not  respond  to  at- 
tempts at  dilatation.  These  must  be  cut,  and  a  much  more  satis- 
factory result  may  be  obtained  from  an  external  than  from  an 
internal  section.  Such  a  complication  of  stricture  as  stone  in 
the  bladder  naturally  calls  for  perineal  section,  since  two  mala- 
dies may  thus  be  overcome  by  a  single  operation. 

PERINEAL   SECTION    WITH    A    GUIDE. 

This  is  as  simple  an  operation  as  can  well  be  performed. 
No  effort  should  be  spared  and  no  time  grudged  that  may  be 
necessary  to  effect  the  passage  of  a  tight  stricture  with  a  whale- 
bone guide;  the  life  of  a  patient  may  hang  upon  so  slight  a 
thread. 

The  guide  having  been  passed,  the  patient  should  be  ether- 
ized and  bound  in  the  lithotomy  position.  The  perineum  should 
be  cleanly  shaved.  As  instruments — besides  sponges,  artery- 
forceps,  ligatures,  a  Guyon's  tampon  (Fig.  40)  if  deep  haemor- 
rhage be  feared,  a  scalpel,  and  a  straight,  narrow  bistoury — it  is 
well  to  have  two  sizes  of  Gouley's  grooved  catheter  (Fig.  41,  a). 
This  instrument  is  tunnelled,  and  makes  an  excellent  substitute 
for  Syme's  old-fashioned  dangerous  instrument,  with  a  shoulder  of  steel 
and  a  long,  sharp,  curved  point.  A  needle-holder  is  useful  with  two 


Pia.  41. 


curved  needles  carrying  long,  stout,  waxed  silk  ligatures  at  least  three 
feet  long.     A  blunt  steel  sound,  grooved  to  its  tip,  which  latter  should 


320  THE    VENEREAL    DISEASES. 

be  tunnelled  for  the  guide,  will  answer  very  well  if  Gouley's  grooved 
catheter  is  not  at  hand. 

The  patient  being  drawn  well  to  the  edge  of  the  table,  with  his  knees 
up  and  his  hips  elevated,  the  operator  sits  in  front  of  him,  passes  the  tun- 
nel of  the  catheter  over  the  whalebone,  which  lias  been  previously  intro- 
duced as  a  guide  through  the  obstruction,  and  carries  it  down  to  the  face  of 
the  stricture.  He  then,  with  the  scrotum  and  testicles  drawn  well  up 
out  of  the  way,  entrusts  the  instrument  to  his  first  assistant,  and  pro- 
ceeds to  cut  down  methodically  in  the  middle  line,  layer  after  layer,  aiming 
for  the  tip  of  the  sound,  which  of  course  represents  the  anterior  face  of 
the  stricture.  As  soon  as  the  tip  of  the  sound  has  been  exposed,  the 
curved  needles  are  deeply  inserted  on  either  side  through  the  skin  and 
deep  tissues,  and  brought  out  through  the  urethral  mucous  membrane,  just 
in  front  of  the  anterior  face  of  the  stricture,  near  the  tip  of  the  sound. 
The  needles  being  removed,  each  ligature  is  knotted  to  itself,  so  as  to 
form  a  loop  on  either  side.  The  loops  are  entrusted  to  two  assistants. 
They  form  the  best  possible  means  of  keeping  the  wound  open  without 
the  use  of  fingers  or  instruments,  which  obstruct  the  light,  and  allow  the 
whole  bottom  of  the  deep  wound  to  be  freely  inspected,  showing  the  end 
of  the  guide  disappearing  through  the  stricture,  among  the  tissues  which 
have  stopped  the  tip  of  the  tunnelled  catheter. 

It  is  now  but  the  work  of  a  moment.  A  little  delicate  dissection  in 
the  middle  line,  following  the  black  guide,  and  the  operation  is  over. 
Care  is  necessary  not  to  cut  off  the  slender-  whalebone  in  the  wound. 
The  catheter  may  now  be  easily  slid  forward  into  the  bladder,  a,nd  the 
removal  of  its  stylet  allowing  the  urine  to  flow  freely  through  it,  demon- 
strates the  success  of  the  operation. 

The  catheter  should  now  be  withdrawn,  and  the  site  of  the  stricture  ex- 
amined. If  this  has  involved  the  roof  as  well  as  the  floor  of  the  urethra, 
a  bridge  across  the  roof,  generally  with  a  slight  pocket  above  and  in  front, 
will  be  noticed.  This  should  be  thoroughly  cut  through,  or  it  may  prove 
a  serious  obstacle  to  the  introduction  of  sounds  while  the  wound  is  heal- 
ing. On  one  occasion  I  saw  this  operation  performed  by  an  experienced 
surgeon.  He  neglected  to  cut  this  bridge  in  the  roof  of  the  urethra,  and, 
as  a  consequence,  was  unable  to  pass  sounds  afterward.  The  operation 
had  to  be  repeated  under  ether  before  the  patient  was  put  in  a  position  to 
recover.  The  importance  of  this  little  step  in  the  operation  becomes  ap- 
parent when  it  is  remembered  that,  the  floor  being  cut,  the  roof  of  the 
urethra  is  the  only  safe  guide  to  the  bladder  after  the  operation  of  peri- 
neal  section. 

Bleeding  points  next  require  attention,  and  finally,  the  bladder  should 
be  thoroughly  examined  for  stone,  and  the  finger  should  assure  the  opera- 
tor that  all  the  hard,  fibroid  tissue  constituting  the  stricture  has  been 
thoroughly  cut  through  at  each  end  of  the  wound.  The  pendulous  ure- 
thra should  also  be  examined  for  stricture,  which  should  be  cut  if  found; 
and,  above  all  things,  the  surgeon  must  convince  himself  that  he  can  easily 
pass  a  full-sized  conical  steel  sound  into  the  bladder  through  the  meatus, 
and  without  putting  his  finger  into  the  wound.  If  he  cannot  do  this  he 
should  find  out  the  reason  for  his  failure,  and  so  study  the  urethra  that 
he  may  become  familiar  with  all  its  peculiarities,  and  thus  become  master 
of  the  situation;  for  these  things  he  may  not  be  able  to  investigate  after 
the  patient  has  aroused  from  his  anaesthetic. 

The  application  of  a  tampon  is  very  rarely  required.  If  one  is  placed, 
it  should  be  perforated  centrally  by  a  catheter;  or,  if  Guyon's  rubber  tarn- 


STEICTUEE    OF    SMALL    CALIBKE.  321 

pon  is  used,  the  catheter  forms  part  of  the  instrument.  Under  no  other 
circumstances  is  it  allowable  to  leave  any  instrument  whatsoever  in  the 
bladder,  either  passed  through  the  wound  or  through  the  urethra.  Such 
instruments  are  wholly  unnecessary.  Their  use  serves  only  to  give  the 
patient  discomfort  and  fever ;  they  inflame  the  urethra,  so  that  it  cannot 
readily  take  a  full-sized  instrument  while  the  wound  is  healing,  and  thus 
greatly  mar  the  ultimate  success  of  the  operation.  They  cannot  protect 
the  cut  surfaces  from  contact  with  the  urine,  and  are  far  more  an  occa- 
sion for  high  urinary  fever  than  a  protection  against  it.  In  short,  any 
catheter  left  in  the  bladder  is  a  source  of  pain  and  danger  to  the  patient, 
and  an  annoyance  to  the  surgeon.  Although  its  use  is  still  advocated  in 
some  quarters,  I  am  unable  to  discover  upon  what  grounds  it  is  advised, 
and  having  seen  it  occasionally  used  in  hospitals,  I  cannot  refrain  from 
totally  condemning  it.  The  wound  should  be  left  open  for  the  passage  of 
the  urine,  and  the  after-treatment  should  be  conducted  upon  ordinary 
surgical  principles,  so  far  as  attention  to  the  wound,  to  fever,  to  diet, 
etc.,  is  concerned.  The  scrotum  must  be  strapped  up  well  out  of  the 
•way  of  the  wound,  or  it  may  become  excoriated,  cedematous,  perhaps  infil- 
trated with  urine. 

In  twenty-four  hours,  before  suppuration  has  become  fairly  established, 
a  full-sized  conical  steel  sound  should  be  gently  carried  into  the  bladder 
from  the  meatus,  following  the  roof  of  the  canal.  This  serves  to  over- 
come the  tendency  of  the  cut  surfaces  to  rapid  union.  After  an  interval 
of  forty-eight  hours,  another  sound  may  be  passed,  generally  one  or  two 
sizes  smaller.  Then,  at  intervals  of  three  or  four  days,  the  largest  conical 
steel  sound  that  will  go,  should  be  gently  carried  through  the  whole 
course  of  the  urethra  into  the  bladder,  and  this  continued  at  gradually 
lengthening  intervals  until  the  wound  has  healed — a  time  generally  vary- 
ing from  three  to  six  weeks. 

It  is  by  no  means  necessary,  however,  to  confine  the  patient  to  the 
house,  much  less  to  his  bed,  during  the  whole  of  this  period.  His  peri- 
neal  wound  is  a  matter  of  little  importance.  A  greased  rag,  some  oakum, 
and  a  T-bandage  will  keep  him  perfectly  clean,  and  he  may  get  up  when 
he  feels  inclined,  and  walk  about.  I  have  had  an  old  man  past  sixty, 
whom  I  cut  most  extensively  in  the  perineum,  up,  dressed,  and  walking 
about  upon  the  eighth  day.  This  would  not  have  been  at  all  possible  had 
any  instrument  been  left  in  the  bladder  after  the  operation. 

Finally,  when  the  patient  gets  well,  he  must  be  taught  to  use  a  full- 
sized  conical  steel  sound  for  himself,  once  a  week,  just  as  after  internal 
tirethrotomy  or  divulsion  practised  upon  a  tight  organic  stricture  in  the 
deep  urethra,  or  his  cure  may  not  be  lasting.  Many  a  patient  relapses 
into  a  condition  of  impermeable  stricture,  after  having  been  thoroughly 
cut  in  the  perineum,  either  because  his  surgeon  has  not  impressed  him 
with  the  necessity  of  using  sounds,  or  because  he  himself  has  been  neg- 
ligent in  his  duty.  I  have  cut  a  number  of  such  patients,  who  had  already 
undergone  the  operation  several  years  previously. 

What  comment  more  striking  than  this  is  necessary  to  confute  the 
.claims  of  those  who  assert  that  internal  urethrotomy,  if  only  the  incision 
be  deep  enough,  will  radically  cure  stricture  ?  Here  all  morbid  tissue  is 
cut  under  the  eye,  -including  the  healthy  tissues  and  skin,  and  yet  recon- 
traction  follows,  unless  a  sound  be  continuously  used.  Stricture  of  large 
calibre  in  the  pendulous  urethra  is  one  thing;  deep  organic  stricture 
is  another. 

But  recontraction  is  not  invariable  after  perineal  section.  I  cut  with- 
21 


322  THE    VENEREAL    DISEASES. 

out  a  guide,  about  nine  years  ago,  a  boy  with  impermeable  stricture,  re- 
tention, and  overflow,  who  had  already  been  cut  by  a  surgeon  two  years 
previously,  in  the  perineum,  for  the  same  stricture.  The  patient  had  fallen 
on  the  crotch  when  a  child,  and  crushed  his  perineum,  a  part  of  which, 
with  some  of  the  urethra,  had  sloughed  away.  After  his  first  operation, 
sounds  had  been  passed  seven  times  by  his  surgeon,  on  each  occasion 
under  an  anaesthetic,  and  then  the  boy  had  been  told  he  was  well. 

In  this  case  I  followed  the  patient  up,  and  have  seen  him  this  year  (1879). 
For  a  year  or  more,  a  sound  was  passed  weekly  without  ether,  then  at 
gradually  lengthening  intervals,  until,  six  years  after  his  cut,  the  sound 
was  passed  only  once  a  quarter.  Then  six  months  went  by,  and  there  was 
no  recontraction ;  finally,  after  an  interval  of  a  year,  the  boy,  meantime, 
having  grown  enormously  and  developed  in  every  way,  I  examined  his 
urethra,  and  found  that  the  strictured  point  was  two  sizes  larger  than  it 
had  been  the  year  before,  at  the  last  examination.  I  then  considered  him 
cured,  and  he  has  remained  perfectly  well,  so  far  as  his  urethra  is  con- 
cerned. This  case  is  certainly  exceptional.  I  only  refer  to  it  as  an  au- 
thentic instance  of  cure  of  deep  organic  stricture  after  perineal  section. 


PEBINEAL   SECTION   WITHOUT   A    GUIDE. 

This  operation  is  a  formidable  one  on  account  of  the  element  of  un- 
certainty which  it  involves.  Generally  it  is  finished  quite  promptly,  even 
under  the  employment  of  great  care  and  all  known  means  to  insure  the 
safety  of  the  patient;  yet  the  best  surgeons  have  worked  hours  over  a  case 
without  reaching  the  bladder.  An  excellent  surgeon  in  New  York,  on 
one  occasion,  failing  to  enter  the  bladder,  when  daylight  deserted  him, 
at  the  close  of  an  afternoon's  hard  work  in  cautious  attempts  to  find  a  way 
into  the  bladder  in  such  a  case,  sent  his  patient  back  to  the  wards,  and  an- 
nounced to  the  surgeons  standing  around  that  the  operation  would  be 
resumed  at  two  o'clock  on  the  following  day.  Generally,  I  repeat,  the  op- 
eration without  a  guide  is  easy  to  a  cool-headed  surgeon,  only  a  few 
minutes  being  required  after  the  front  face  of  the  stricture  is  exposed 
before  a  passage  into  the  bladder  is  obtained;  but,  in  spite  of  this,  no  one 
can  afford  to  laugh  at  the  difficulties  of  the  operation,  and  no  prudent 
surgeon  will  undertake  it  without  an  abundance  of  daylight  before  him. 
One  incident,  which  I  witnessed,  may  serve  to  impress  the  reader,  both 
with  the  difficulties  occasionally  encountered  in  the  operation,  and  with 
the  folly  of  those  who  pretend  that  a  guide  should  be  used  only  by  be- 
ginners. No  reputable  surgeon  can  afford  to  disregard  any  aid  to  an  oper- 
ation which  gives  the  patient  a  greater  chance  for  his  life.  All  operations 
upon  the  deep  urethra  are  capital,  and  involve  the  issues  of  life  and  death. 

The  case  I  have  just  referred  to  is  the  following:  a  young,  but  per- 
fectly competent  surgeon,  attempted  perineal  section  without  a  guide,  in 
a  case  of  impermeable  stricture.  After  long  and  cautious  work  he  failed 
to  reach  the  bladder,  having  passed  under  and  to  one  side  of  the  mem- 
branous urethra,  and  reached  just  beyond  the  apex  of  the  prostate.  The 
patient  had  no  retention,  and  the  surgeon,  after  appealing  to  those  around 
him,  determined  to  postpone  any  further  work  for  the  day,  when  a  sur- 
geon in  high  position  and  with  a  widespread  reputation  as  a  general  oper- 
ator, entered  the  operating-room.  He  was  told  the  condition  of  affairs, 
called  for  a  silver  catheter,  passed  it  through  the  meatus,  put  his  fingor 
iitto  the  wound  and  manipulated  for  a  moment.  Presently  he  depressed 


STRICTUEE    OF    SMALL    CALIBRE.  323 

the  handle  of  the  catheter  with  some  force,  and  called  for  a  bowl.  Clear 
urine  flowed  through  the  catheter,  and  with  a  smile  of  satisfaction,  amid 
a  spontaneous  burst  of  applause  from  the  assembled  doctors,  the  surgeon 
withdrew. 

At  the  autopsy  on  the  following  day  a  round  hole  was  found  passing 
through  one  lobe  of  the  prostate  into  the  bladder. 

The  operation  of  perineal  section  without  a  guide  calls  for  the  same 
preparations  as  if  a  guide  were  to  be  used.  A  few  fine  probes,  directors, 
and  a  female  catheter,  are  also  necessary.  A  last  attempt  under  ether 
should  always  be  made  to  pass  a  whalebone  guide.  Failing  in  this,  the 
grooved  sound  or  catheter  is  introduced  as  far  as  the  front  face  of  the 
stricture,  entrusted,  with  the  scrotum,  to  an  assistant,  arid  central  inci- 
sions are  made  as  before,  the  point  of  the  sound  exposed,  the  long  threads 
passed,  and  the  loops  handed  to  assistants. 

Now  the  operator  carefully,  with  fine  whalebone  or  silver  probes, 
searches  cautiously  on  the  front  face  of  the  stricture  for  the  way  through 
into  the  bladder.  To  aid  him  he  may  enlarge  any  existing  perineal  fis- 
tula, and  try  by  that  route  to  reach  the  posterior  face  of  the  obstruction 
within  the  urethra.  Posterior  catheterism  has  been  and  may  again  be 
tried  from  the  bladder  through  an  opening  made  above  the  pubes,  or 
puncture  of  the  (perhaps)  dilated  urethra  behind  the  stricture  ;  but  I 
think  that  neither  of  these  processes  is  advisable  for  general  use. 

Usually  the  best  guide  to  the  bladder  is  a  clear  anatomical  understand- 
ing of  just  where  the  hole  in  the  triangular  ligament  is,  and  in  what  re- 
lation that  hole  stands  to  the  lower  edge  of  the  subpubic  ligament. 
This  lower  edge  of  the  subpubic  ligament  can  always  be  felt;  and  be- 
neath it,  exactly  in  the  middle  line,  about  three-quarters  of  an  inch  below 
the  symphysis,  varying  a  little  in  different  subjects,  lies  the  hole  in  the 
triangular  ligament.  This  hole  is  generally  the  operator's  objective  point. 
The  tendency  is  to  cut  too  much  at  first  and  to  probe  too  little,  until  the 
operator  loses  his  bearing  in  the  solid  mass  of  tissues  matted  together  by 
prolonged  inflammation;  and  once  fairly  off  the  track,  he  rarely  recovers 
his  position  by  any  other  means  than  accident.  Patient  and  judicious 
probing,  with  a  little  careful  cutting  in  the  anatomical  position  of  the 
closed  urethra,  is  generally  rewarded  with  prompt  success;  the  probe  soon 
passes  on  without  obstruction  for  a  considerable  distance  in  the  direction 
of  the  bladder,  another  probe  may  be  pushed  alongside  of  the  first,  and 
a  separation  of  these  two  allows  a  little  bloody  urine  to  flow  out.  The 
tight  ring  surrounding  the  probes  may  now  be  carefully  followed  up  with 
the  knife  for  a  short  distance,  the  area  of  the  canal  widens,  a  female  ca- 
theter passes  readily  alongside  the  probes,  and  a  gush  of  bloodless  urine 
through  it  announces  that  the  bladder  has  been  reached. 

One  of  the  most  common  causes  of  failure  in  this  operation  is  the  ex- 
istence of  a  false  passage,  starting  from  the  front  face  of  the  stricture, 
the  result  of  some  former  rude  attempt  to  pass  the  stricture  with  a  solid 
instrument.  The  surgeon  may  be  led  on  by  such  a  false  route  far  astray, 
and  find  his  mistake  only  after  he  has  hopelessly  lost  his  bearings  among 
the  diseased  tissues.  It  is  well,  therefore,  not  to  follow  up  any  inviting 
sinus  without  first  dilating  it  a  little  and  learning  whether  it  leads  in  the 
proper  direction. 

After  the  bladder  has  been  reached,  the  operation  of  perineal  section, 
with  and  without  a  guide,  are  one  and  the  same.  No  further  description 
of  the  remaining  steps  is  therefore  necessary,  since  they  have  been  al- 
ready given.  I  desire  to  repeat  here,  however,  that  on  no  account  is  any 


324  THE    VENEREAL   DISEASES. 

instrument  to  be  left  in  the  bladder  after  the  operation;  and  on  no  ac- 
count is  the  patient  to  be  discharged  as  cured  until  he  has  been  taught  to 
pass  a  full-sized  conical  steel  instrument  for  himself,  and  has  been  im- 
pressed with  the  necessity  for  doing  this  with  regularity,  at  weekly  inter- 
vals, until  he  can  demonstrate  to  the  satisfaction  of  a  surgeon  that  no 
further  recontraction  is  taking  place. 


UBETHRAL   FEVEB. 

All  operations  upon  the  deep  urethra  contain  an  element  of  danger  to 
life.  The  simple  passage  of  a  catheter,  the  introduction  even  of  a  single 
smooth  sound,  has  been  followed  by  death  within  twenty-four  hours,  the 
patient  dying  with  a  high  temperature,  following  chill  more  or  less  severe 
and  prolonged,  and  the  autopsy  showing  nothing  worse,  as  a  lesion,  than 
the  remains  of  a  passing  congestion  of  the  kidneys.  These,  of  course, 
are  extreme  cases. 

Ordinary  urethral  or  urinary  fever,  however,  is  very  common.  It 
comes  on  with  a  chill,  sometimes  only  a  cold  sensation,  and  this  chill  ush- 
ers in  a  fever.  The  chill  may  occur  during  the  operation  or  just  after  it, 
or  anywhere  within  the  twenty-four  hours — rarely  later;  perhaps  from  six 
to  twelve  hours  after  the  operation  is  the  time  during  which  chill  is  most 
often  observed. 

This  chill,  and  the  succeeding  fever  and  sweat,  commonly  mean  nothing. 
They  leave  the  patient  prostrated,  and  feeling  weak  and  miserable  for 
several  days,  often  with  a  crop  of  herpes  about  his  mouth.  Such  attacks 
of  urethral  fever  occur  as  well  after  the  simple  passage  of  an  instrument 
which  brings  no  blood,  as  after  the  most  severe  operations.  Their  cause 
is  unknown.  They  are  far  more  common  in  patients  with  defective  kid- 
neys than  in  sound  men,  and  more  frequent,  1  believe,  in  nervous,  impres- 
sionable people  than  in  others,  especially  if  fear  of  the  result  was  felt  at 
the  time  of  the  operation.  Nervous  shock,  reflected  from  the  point  oper- 
ated upon  to  the  rest  of  the  body,  and  especially  to  the  urinary  system, 
seems  to  be  at  the  bottom  of  most  of  the  cases.  If  the  kidneys  are  sound, 
no  evil  results  beyond  temporary  depression;  if  the  kidneys  are  defective, 
death  may  rapidly  ensue.  Hence  the  necessity  of  making  up  one's  mind 
about  the  probable  structural  condition  of  the  kidneys  before  attempting 
any  operation  upon,  or  even  exploration  of,  the  urethra. 

And  yet  diseased  kidneys  do  not  necessarily  render  a  patient  unfit  for 
an  operation.  Many  a  severe  operation  is  done  of  necessity,  upon  the 
urethra  and  bladder  of  patients  well  known  to  have  defective  kidneys, 
and  they  escape  without  a  chill. 

There  seems  to  be  some  connection  between  slight  over-distention  of 
a  stricture  and  urethral  fever.  Thompson  mentions  the  fact,  and  I  have 
seen  cases  where  a  patient  will  do  well  enough  while  using  a  certain  sized 
sound,  but  where  each  attempt  to  employ  a  larger  size  has  been  followed 
by  a  chill. 

In  one  such  case,  an  old  gentleman,  finding  that  dilatation  could  not 
be  pushed  on  account  of  the  recurrence  of  urethral  fever,  I  employed  di- 
vulsion  with  the  effect  of  curing  the  stricture  by  splitting  it,  and  that,  too, 
without  giving  the  old  man  any  chill  at  all;  so  that  it  cannot  be  the  vio- 
lence of  stretching  alone  which  causes  chill  in  these  cases,  but  some  per- 
sistence of  irritation  in  the  stretched  fibres,  for  when  the  fibres  are  broken 
by  divulsion,  no  chill,  of  necessity,  follows. 


STRICTURE    OF   SMALL   CALIBRE.  325 

It  certainly  is  not  urinary  absorption,  as  the  French  have  claimed, 
which  causes  urethral  fever.  The  meatus  may  be  widely  cut  on  the  floor, 
at  a  point  where  absorption  is  known  to  be  most  active  and  the  lymphat- 
ics very  abundant;  yet  it  is  the  rarest  thing  in  the  world  for  any  urethral 
fever  to  follow  this  operation  if  no  instrument  be  used  farther  down  the 
canal,  and  this,  too,  in  spite  of  the  fact  that  the  urine  may  be  ammoniacal 
or  even  putrid.  Many  old  men  with  diseased  bladders,  perhaps  passing 
blood  in  considerable  quantities,  from  raw  surfaces  kept  irritated  by  the 
constant  use  of  the  catheter,  do  not  have  any  urethral  fever  at  all  for 
weeks,  when  on  some  occasion,  perhaps  so  slight  a  one  as  a  simple  explo- 
ration of  the  urethra,  often  without  known  cause,  a  sudden  attack  of  ure- 
thral fever  will  come  on. 

Consequently,  we  do  not  know  accurately  what  urethral  fever  is,  or 
why  it  comes  at  certain  times  and  not  at  others,  or  why  the  same  appar- 
ent combinations  of  causes  will  not  always  produce  it.  But  this  much  is 
known  quite  certainly:  that  (1)  the  deeper  down  the  urethra  an  operation 
or  exploration  extends,  the  more  likely  is  urethral  fever  to  follow;  (2) 
operations  near  the  meatus  very  seldom  cause  urethral  fever;  (3)  over- 
stretching a  stricture  without  rupturing  it  is  more  apt  to  cause  the  fever 
than  when  the  fibres  are  divulsed  or  cut;  (4)  one  attack  by  no  means  pre- 
supposes another,  though  the  same  causes  may  be  brought  into  play; 
many  a  patient  has  one  attack  of  urethral  fever  at  the  beginning  of  his 
treatment  for  stricture  by  dilatation,  and  never  is  troubled  again,  although 
the  treatment  by  dilatation  is  continued;  (5)  other  things  being  equal, 
fever  and  nervous  impressionability  make  urethral  fever  more  apt  to  occur 
after  interference  with  the  urethra;  (6)  organic  kidney  disease  makes 
urethral  fever  more  likely  to  occur,  and  more  apt  to  prove  fatal,  than  if 
that  condition  did  not  exist;  (7)  the  occurrence  of  urethral  fever  cannot 
be  ascribed  to  urinary  absorption. 

One  very  serious  obstacle  to  a  successful  study  of  urethral  fever  is  that 
there  is  no  means  of  knowing  whether  a  given  chill  following  an  opera- 
tion on  the  urethra  or  bladder  is  a  chill  of  urethral  fever,  or  due  to  some 
other  cause — that  is,  there  is  no  important  or  essential  difference  in  the  chill 
itself.  Thus,  an  outbreak  of  malaria  following  an  operation  on  the  urethra 
is  usually  mistaken  at  first  for  urethral  fever;  and  so  also  with  any  chill 
which  may  be  a  starting-point  of  pyaemia,  of  epididymitis,  cystitis,  or  of 
some  other  malady  having  nothing  to  do  with  the  urinary  organs.  As  a 
general  thing  it  may  be  said,  however,  that  the  chill  of  urinary  fever 
comes  certainly  within  twenty-four  hours  of  the  immediate  cause — the  in- 
jury to  the  urethra — while  chills  having  some  other  significance  come  later, 
as,  for  instance,  the  chill  at  the  beginning  of  surgical  fever  following  peri- 
neal  section. 

Finally,  it  may  be  said  of  true  urethral  fever  that  there  is  a  certain 
habit  about  it  in  some  patients.  I  have  known  a  hospital  patient,  who 
persistently  through  a  number  of  weeks  after  instrumentation  had  sharp 
urethral  fever,  a  temperature  reaching  105°  Fahrenheit  and  prostrating 
him  for  days,  who  had  his  fevers  warded  off  by  the  treatment  which  will  be 
given  below;  and  then,  after  having  an  instrument  passed  a  few  times  and 
escaping  chill  by  these  means,  it  became  possible  to  introduce  a  sound 
without  taking  any  precautions,  and  still  no  chill  followed. 

The  study  of  this  malady  is  curious  and  instructive,  but  not  very  sat- 
isfactory, because  so  uncertain. 

Something  can  be  done,  however,  toward  warding  off  urethral  fever 
and  modifying  its  intensity  when  it  does  occur. 


326  THE    VENEREAL    DISEASES. 

Treatment  of  urethral  fever. — The  most  important  treatment  is 
such  as  shall  prevent  chill,  when  it  is  found  necessary  to  operate  upon  a 
given  urethra.  Quinine,  formerly  much  used,  is  not  to  be  depended  upon. 
I  cannot  say  that  it  is  without  value,  but  long  experience  with  it  has 
made  me  unwilling  to  trust  to  it  alone. 

If  a  patient  has  casts  and  albumen  in  a  specimen  of  urine  which 
does  not  contain  blood,  he  should  be  prepared  beforehand  by  treatment 
for  his  exploration  or  operation,  as  the  case  may  be.  He  may  receive 
with  advantage,  for  several  days  before  the  operation,  a  mild,  thorough 
diuretic,  such  as  a  tablespoonful  of  the  infusion  of  digitalis  containing 
twenty  grains  of  the  citrate  or  of  the  acetate  of  potash,  during  the  third 
hour  after  each  meal,  and  he  should  be  encouraged  to  drink  milk  and 
plenty  of  bland  fluids — a  laxative  being  added  if  necessary;  this  will  put 
him  as  near  as  may  be  on  a  par  with  other  patients. 

On  the  night  before  an  operation  a  laxative  should  be  administered, 
and  ten  grains  of  quinine  about  two  hours  before  the  operation,  to  get 
from  this  drug  whatever  advantage  it  may  possess,  be  that  advantage  lit- 
tle or  great.  Fifteen  minutes  before  the  operation,  ten  minims  of  Magen- 
die's  solution  of  morphia  may  be  thrown  under  the  skin,  and  immediately 
after  the  operation  fifteen  to  twenty  minims  of  Squibb's  fluid  extract  of 
jaboraudi  may  also  be  inserted  under  the  skin.  Among  these  remedies  I 
estimate  as  most  important  the  morphine,  next  the  jaborandi.  With  the 
jaborandi  alone  I  have  succeeded  in  stopping  chill  in  persons  who  had 
chill  habitually  whenever  the  urethra  was  interfered  with.  My  experi- 
ence with  jaborandi,  however,  is  quite  recent,  and  I  am  unwilling  to  rank 
it  very  high  as  a  preventive  of  chill,  for  fear  that  a  more  extended  trial 
may  disappoint  me  in  my  estimate. 

If  chill  comes  on,  it  is  best  treated,  I  believe,  by  the  immediate  admin- 
istration, during  the  cold  stage,  of  twenty  minims  of  chloroform,  to  be 
repeated  in  fifteen  minutes  if  the  chill  has  not  disappeared  or  is  not  sen- 
sibly modified.  A  small  subcutaneous  dose  of  morphia  may  be  adminis- 
tered at  the  same  time.  Chloroform  is  best  given  in  glycerine  and  water. 
If  the  chloroform  be  first  thoroughly  mixed  with  about  four  parts  of  gly- 
cerine, it  may  be  afterward  diluted  to  any  extent  with  water,  without  be- 
coming separated  and  falling  to  the  bottom  of  the  glass,  as  chloroform 
ordinarily  does  when  thrown  into  water.  This  mixture  is  quite  sharp  to 
the  mouth,  and  requires  plentiful  dilution  with  water.  As  soon  as  the 
chill  breaks,  a  warm  drink,  preferably  without  alcohol,  aids  in  starting 
the  perspiration  and  helps  to  shorten  the  attack.  By  a  judicious  appli- 
cation of  these  means,  ordinary  urethral  fever  may  be  much  modified. 

Not  so,  however,  I  fear,  in  malignant  cases — those  which  kill  in  twenty- 
four  hours.  I  have  not  encountered  such  a  case  for  many  years,  but  their 
character  is  so  desperate  that  it  seems  hopeless  to  do  anything.  In  one 
case  which  I  had  an  opportunity  of  observing  closely,  the  chill — a  sharp 
one — followed  the  operation  (internal  urethrotomy)  promptly,  and  was  in- 
tense in  character.  High  fever  came  on  rapidly,  with  profuse  purging 
and  vomiting,  intense  headache,  and  delirium.  Death  quickly  ended  the 
scene.  One  ureter  was  found  occluded,  and  both  kidneys  diseased.  The 
case  was  one  of  unavoidable  operation,  and  a  record  of  it  was  published 
at  the  time. 

During  the  after-treatment  of  operations,  urethral  fever  is  not  very 
apt  to  come  on,  whether  it  has  or  has  not  attended  the  operation.  During 
all  such  after-treatment,  it  is  desirable  to  keep  the  urine  bland  and  unir- 
ritating,  by  the  use  of  plenty  of  watery  fluids,  abstinence  from  alcohol  in 


STRICTURE    OF    SMALL    CALIBRE.  327 

any  shape,  and  the  use,  if  need  be,  of  the  citrate  of  potash  in  moderate 
(gr.  x.)  doses  during  th'e  third  hour  after  eating,  three  times  daily,  largely 
diluted  with  water.  I  have  sometimes  thought  that  the  influence  of  cold, 
of  indigestion,  and  possibly  even  of  moral  emotions,  put  a  patient  into  a 
condition  where  he  was  more  apt  to  have  urethral  chill  than  when  his 
mind  was  easy,  his  stomach  content,  and  his  nervous  system  not  depressed. 


CHAPTER  VI. 

GONORRHCEA  IN  THE   FEMALE. 

Symptoms,  Complications.  Treatment. — Local  Treatment. — How  to  wash  the  Vagina. 
— Medicated  Vaginal  Injections. — Chronic  Urethritis  and  its  Treatment. — Chronic 
Cervicitis. — Sterility  in  Women  following  Gonorrhoea. 

GONORRHCEA  in  the  female  is  generally  an  intense  vaginitis.  A  vagi- 
nitis  may  occur  which  is  not  due  to  the  contact  of  gonorrhoeal  pus,  pro- 
duced perhaps  by  prolonged  and  excessive  irritation  in  sexual  intercourse, 
by  masturbation,  and  in  various  ways;  by  rape,  or  by  the  violence  of  sex- 
ual intercourse  during  the  first  approaches  where  there  is  no  rape.  Again 
it  may  be  due,  especially  in  young  children,  to  the  presence  of  thread- 
worms, which  have  escaped  from  the  anus  and  reached  the  vagina.  It 
may  also  be  found  in  a  more  or  less  acute  or  chronic  state  in  connection 
with  uterine  diseases  of  various  character,  Avith  pregnancy,  or  with  syphi- 
lis due  to  mucous  patches,  and  the  acrid  discharges  therefrom.  Indeed, 
there  are  a  great  variety  of  causes  capable  of  producing  vaginitis,  which 
are  themselves  not  at  all  gonorrhoeal.  Yet  the  same  statement  may  be 
made  regarding  these  inflammations  as  was  made  concerning  urethritis  in 
the  male,  namely,  the  inflammation  is  apt  to  run  higher  in  true  gonorrhoea 
than  when  the  cause  is  not  virulent;  but  the  treatment,  under  all  circum- 
stances, is  to  be  graded  according  to  the  intensity  of  the  inflammatory 
process,  and  not  according  to  its  cause. 

Gonorrhoea  in  the  female  does  undoubtedly  attack  many  other  struc- 
tures besides  the  vagina.  Both  sets  of  labia  may  be  included  in  the  in- 
flammatory process;  the  vulvo- vaginal  gland  on  either  side  is  frequently 
attacked;  the  urethra  does  not  always  escape,  and  the  malady  may  involve 
the  bladder;  finally,  the  uterus  and  the  ovaries  may  also  pay  tribute  to 
the  general  inflammation,  and  that,  too,  in  a  most  serious  manner. 

Symptoms. — The  first  symptoms  of  gonorrhoea  in  the  female  come 
on  shortly  after  the  application  of  the  cause,  if  that  cause  be  a  combina- 
tion both  of  local  violence  and  of  virulent  pus,  as  is  often  the  case.  When, 
however,  there  has  been  no  violence,  the  period  of  incubation  is  of  several 
days'  duration,  as  it  is  in  the  male,  after  which  the  patient  makes  complaint 
of  a  feeling  of  heat,  weight,  and  itching  about  the  vulva.  This  is  attended 
by  smarting  during  urination,  not  because  the  urethra  is  the  seat  of  disease 
— although  it  may  also  be  involved  from  the  first — but  because  the  ostium 
vaginae,  the  labia  minora,  and  perhaps  the  orifice  of  the  urethra  are  swol- 
len, inflamed,  excoriated,  sensitive,  and  are  scalded  and  irritated  by  the 
contact  of  the  acrid  urine. 

A  secretion  of  pus  soon  begins  to  show  itself.  This  flowing  out  mats 
the  hairs  together,  and  partly  drying  into  sticky  scabs  upon  the  vulva, 
mixed  with  sodden  epithelium  and  rancid  sebaceous  matter,  goes  into  rapid 
decomposition,  and  emits  a  disgustingly  offensive  odor.  The  labia  become 
excoriated  and  swell  up  with  oedema,  so  that  walking  or  sitting  may  be- 
come quite  painful. 


GONORRHCEA  IN  THE  FEMALE.  329 

Meantime,  should  the  inflammation  travel  down  the  ducts,  as  it  may, 
and  take  possession  of  one  or  both  of  the  vulvo-vaginal  glands,  a  serious 
complication  ensues  in  the  shape  of  a  slow  and  painful  suppuration  of  the 
gland,  which  may  so  increase  the  local  swelling  and  pain,  as  to  make 
walking  practically  impossible. 

The  amount  of  pus  discharged  increases  rapidly.  It  becomes  thick, 
green,  and  offensive,  perhaps  mingled  with  blood.  In  acute  cases  the  in- 
side of  the  vagina  becomes  raw  and  painful,  so  that  any  attempt  to  intro- 
duce a  distending  instrument  into  the  canal  occasions  great  pain. 

This  condition  of  affairs  may  continue  for  several  weeks,  prolonging 
itself  for  months,  perhaps,  in  debilitated  patients  in  a  subacute  or  chronic 
form.  The  duration  of  the  malady  is  greatly  influenced  by  treatment. 
An  uncomplicated  case,  although  quite  acute,  ought  to  be  practically  un- 
der control  in  from  three  to  five  weeks. 

Should  the  uterine  canal  take  fire,  as  it  may,  intra-uterine  inflamma- 
tion, abscess  of  the  Fallopian  tubes,  ovaritis,  and  pelvic-peritonitis  are 
among  the  possible  complications.  They  are  not  very  common,  but  they 
do  occur,  leading  sometimes  to  a  fatal  result.  The  symptoms  of  these 
various  maladies  find  their  description  naturally  in  text-books  devoted  to 
the  consideration  of  uterine  disease.  There  is  nothing  peculiar  or  special 
about  them  to  rank  them  as  venereal  in  any  sense,  excepting  that  of  coin- 
cidence, and  the  nature  of  the  cause  does  not  modify  the  treatment  ordi- 
narily applicable  to  the  same  morbid  states  due  to  other  causes  not  vene- 
real. Consequently,  there  is  no  occasion  to  do  more  than  mention  these 
possible  complications  here. 

Such  other  complications,  as  vulvar  abscess,  not  in  the  vulvo-vaginal 
gland,  peri-vaginal  suppuration  and  abscess  of  one  or  more  of  the  ingui- 
nal glands,  are  exceptionally  uncommon  with  vaginitis,  although  occasion- 
ally encountered. 

Treatment. — Rest  and  absolute  cleanliness  are  two  factors  essential 
to  the  proper  treatment  of  vaginal  inflammation.  The  patient  should  be 
forced  to  keep  her  bed.  This  she  will  the  more  willingly  do  as  the  grade 
of  the  inflammation  runs  high,  since  very  often  the  pain  on  attempting  to 
get  about  is  considerable. 

No  collection  of  pus  about  the  vulva  should  be  allowed.  The  parts 
should  be  constantly  washed  with  mild  (half  of  one  per  cent.)  solutions  of 
carbolic  acid,  or  a  little  Labarraque  solution  in  water,  or  with  water  tinted 
to  a  faint  purple  with  permanganate  of  potash.  Thin  cloths,  moistened 
in  one  of  these  solutions,  should  be  kept  constantly  upon  the  vulva.  It  is 
well  also,  for  the  sake  of  cleanliness,  to  cut  away  the  hairs.  Frequent 
warm  sitz-baths  of  short  duration,  one  every  two  to  three  hours,  are  very 
useful,  and  are  comforting  to  the  patient  as  well. 

Should  abscess  form  in  the  vulvo-vaginal  gland,  no  modification  in  the 
treatment  is  called  for.  A  poultice  is  not  necessary,  and  does  not  give 
any  more  relief  than  the  moist  applications  and  the  warm  local  baths  used 
for  the  sake  of  cleanliness.  When  pus  forms  it  may  be  let  out  by  a  free 
incision,  but  the  integument  should  not  be  incised  until  the  pus  has  nearly 
reached  the  surface,  since  abscess  in  this  region  frequently  disappears  by 
absorption.  Sometimes  the  abscess  discharges  through  or  alongside  the 
duct.  • 

After  abscess  of  a  vulvo-vaginal  gland  has  discharged  spontaneously,  or 
has  been  opened  by  the  surgeon,  the  thickening  about  the  gland  continues 
for  a  long  time,  and  the  opening  remains  fistulous.  The  discharge  from 
such  a  fistula  may  get  to  be  very  annoying,  and  the  pus  which  Hows  away 


330  THE    VENEREAL   DISEASES. 

is  believed  by  many  long  to  retain  infectious  properties.  When,  there- 
fore, this  condition  of  things  exists,  and  seems  likely  to  continue,  three 
courses  are  open  to  the  surgeon:  injection  by  iodine,  cauterization,  exci- 
sion. 

Injection  by  iodine  cannot  be  relied  on.  In  some  mild  cases,  however, 
in  atonic  subjects  it  may  so  stimulate  the  sluggish  cavity  of  the  abscess 
as  to  produce  granulations  which  fill  it  up  if  the  fistula  be  dependent,  so 
that  the  discharges  may  drain  away  as  soon  as  formed. 

Incision  with  cauterization  is  an  effective  means  of  curing  these  chronic 
abscesses.  The  incision  should  involve  the  opening  (or  openings  if  there 
be  more  than  one),  and  lie  in  the  long  axis  of  the  labium.  It  should  be 
very  free  and  largely  open  up  the  cavity  of  the  abscess.  After  arresting 
the  flow  of  blood,  the  fistula  and  abscess  should  be  thoroughly  cauterized, 
either  with  pure  nitric  acid,  a  stick  of  nitrate  of  zinc,  chloride  of  zinc,  or 
nitrate  of  silver,  or  any  efficient  caustic,  the  point  being  to  do  it  thoroughly. 
Cauterization  may  be  very  efficiently  performed  in  these  cases  with  a 
Pacquelin's  naphtha  cautery,  or  with  the  electro-cautery.  The  wound  may 
be  packed  with  carbolized  cotton  or  oakum,  and  poulticed  after  forty- 
eight  hours  to  assist  the  separation  of  the  slough.  As  soon  as  the  wound 
cleans  up  it  may  be  dressed  with  pure  balsam  of  Peru,  and  usually  goes 
on  at  once  to  rapid  granulation  and  cicatrization. 

Excision  is  equally  or  more  effective  than  the  preceding  treatment, 
and  quicker  in  its  results.  It  consists  in  cutting  down  in  the  long  axis 
of  the  labium  upon  the  inflamed  hard  tissues,  representing  the  remains 
of  the  gland  and  dissecting  them  out  bodily.  The  wound  is  dressed  sim- 
ply and  left  to  granulate. 

But  to  return  to  the  acute  gonorrhoea  in  the  vagina — local  treatment 
must  be  relied  upon  for  its  cure.  An  alkaline  diuretic  may  be  adminis- 
tered by  the  mouth  to  make  the  urine  less  scalding  when  it  comes  into 
contact  with  the  abraded  vulva;  but  the  balsams,  so  useful  in  the  male,  are 
of  little  or  no  value  in  the  female,  because  the  urethra  is  not  the  main 
seat  of  the  disease.  Some  good  may  be  effected  by  these  remedies  in 
gonorrhoeal  conditions  of  the  urethra  and  bladder,  but  they  do  not  con- 
trol the  main  malady — vaginitis. 

The  abortive  treatment  of  vaginal  gonorrhoea,  once  much  vaunted, 
does  not  seem  to  hold  its  place  in  the  estimation  of  authors.  Certainly 
it  often  fails,  and  when  it  fails  the  patient's  condition  is  worse  than  if  it 
had  never  been  tried.  Its  value  is  so  problematical  that  it  cannot  be 
recommended. 

The  rational  local  treatment  of  gonorrhceal  vaginitis  is  one  which 
regulates  the  strength  of  the  local  application  by  the  stage  and  intensity 
of  the  inflammation,  and  the  effect  produced.  Cleanliness  within  the 
vagina  is  as  necessary  as  it  is  outside.  The  pus  must  be  washed  away 
from  the  irritated  mucous  membrane,  and  the  oftener  this  is  done  the  bet- 
ter. All  instrumentation  within  the  vagina  is  painful  during  the  acute 
stage  of  gonorrhoea,  but  nevertheless,  no  washing  of  the  canal  can  be 
effective  except  through  an  instrument  introduced  well  up  to  the  cervix. 
Nothing  is  better  for  this  purpose  than  the  ordinary  glass  vaginal  'tube 
of  the  common  fountain  syringe.  Davidson's  syringe  has  the  defect  of 
throwing  in  the  fluid  spasmodically  and  with  too  much  force  both  for 
comfort  and  the  safety  to  the  uterus. 

Washing  the  vagina  may  be  conveniently  effected  as  follows:  The 
patient  lies  flat  upon  the  back,  with  the  hips  raised  several  inches  higher 
than  the  shoulders,  and  the  buttocks  resting  either  in  a  bedpan  or  upon 


GONORRHOEA   IN   THE    FEMALE.  831 

a  large  rubber  sheet  in  which  a  crease  is  made  for  the  purpose  of  conduct- 
ing the  fluids  as  they  flow  out  of  the  vulva  over  the  side  of  the  bed  into 
a  vessel  suitably  placed  to  receive  them. 

A  large  fountain  syringe  (or  simple  rubber  bag  with  rubber  tube  and 
long  glass  nozzle),  filled  with  water  as  hot  as  can  well  be  borne  by  the 
vagina,  varying  from  98°  to  110°  Fahrenheit,  or  more  in  some  cases,  being 
ready,  the  glass  vaginal  nozzle  warmed  and  well  oiled  is  slowly  in- 
troduced carefully  along  the  posterior  vaginal  wall  until  its  point  has 
been  carried  well  up  into  the  vaginal  pouch  behind  the  posterior  lip  of 
the  uterus.  In  this  pouch  secretions  are  apt  to  collect  and  to  remain, 
since  ordinary  irrigation  hardly  reaches  them. 

As  soon  as  the  glass  tube  is  in  place,  the  rubber  bag  is  to  be  gently 
raised,  and  shortly  after  the  pus  and  water  begin  to  flow  away  at  the 
vulva,  it  is  again  to  be  raised  higher  so  that  the  force  of  the  flow  of 
water  may  be  increased.  If  the  end  of  the  tube  lies  behind  the  poste- 
rior lip  of  the  cervix  the  force  of  the  flow  cannot  do  harm.  The  posi- 
tion of  the  body  and  the  gradually  increasing  and  finally  maintained  force 
of  the  flow  of  fluid  first  distends  the  vagina  fully,  and  then  washes  it  out 
thoroughly  from  its  deepest  part. 

After  one  bag  of  water  has  flowed  through  the  vagina,  if  the  pus 
has  not  been  all  washed  out,  the  bag  may  be  refilled  and  the  process  re- 
peated. This  vaginal  washing  may  be  renewed  several  times  during  the 
twenty-four  hours,  more  or  less  frequently  according  to  the  rapidity  of 
pus  formation. 

Instead  of  using  simple  hot  water  with  which  to  wash  the  vagina,  a 
little  salt  may  be  added,  or  chlorate  of  potash  or  borax,  one  to  three  tea- 
spoonfuls  to  the  pint,  not  strong  enough  to  produce  any  effect  of  which 
the  patient  may  be  made  conscious  by  her  sensations. 

From  the  very  commencement  of  the  treatment  medicated  injections 
may  be  employed,  after  the  vaginal  wash,  for  the  purpose  of  restraining 
the  activity  of  the  pus  formation,  and  keeping  the  inflammation  within 
reasonable  bounds.  These  injections  should  never  be  made  from  without, 
inward,  or  into  a  vagina  full  of  pus,  but  should  be  thrown  gently  into 
the  depths  of  the  vagina  after  the  canal  has  been  washed.  The  injec- 
tions are  to  be  made  preferably  with  the  same  tube  through  which  the 
washing  has  been  effected.  The  medicated  injection  must,  therefore,  be 
put  either  into  the  fountain  syringe  after  the  water  has  all  escaped,  or 
the  tube  may  be  uncoupled  and  fitted  by  a  piece  of  rubber  to  whatever 
syringe  it  is  proposed  to  employ.  It  is  better  not  to  withdraw  the  vagi- 
nal tube  for  the  purpose  of  introducing  another. 

The  substances  to  be  employed  with  advantage  in  the  vagina  are  sim- 
ilar to  those  found  useful  in  the  urethra  of  the  male.  It  is  not  well  to 
try  a  great  number,  one  after  the  other,  but  to  use  one  or  two,  varying 
the  strength  according  to  the  effect.  In  watching  the  effect  of  an  injec- 
tion, it  is  always  well  to  commence  with  a  mild  solution,  and  to  increase 
the  strength,  if  it  is  well  borne,  until  it  either  modifies  the  quantity  of  the 
pus  or  commences  to  produce  irritation.  If  the  former  result  is  reached, 
the  injection  is  doing  good;  if  the  latter,  it  must  be  abandoned  and  an- 
other one  tried.  Medicated  injections  should  always  be  heated  before  be- 
ing thrown  into  the  vagina,  and  they  should  be  introduced  in  a  continu- 
ous stream,  flowing  without  much  force.  The  substances  which  may  be 
employed  in  solution,  in  the  acute  stage  of  vaginitis,  are  dilute  lead-water; 
pure  sulphate  or  chloride  of  zinc,  commencing  at  half  a  grain  to  the  ounce 
of  water  and  increasing;  lactic  acid,  half  a  minim  to  the  ounce  and  increas- 


332  THE    VENEREAL   DISEASES. 

ing;  bisulphate  of  quinine,  one  grain  to  the  ounce  and  increasing,  dissolved 
in  the  smallest  possible  amount  of  dilute  sulphuric  acid;  or  picric  acid 
(Cheron),  one  grain  to  four  ounces  and  increasing. 

When  some  headway  has  been  made  in  reducing  the  quantity  of  the 
discharge,  or  making  it  thinner,  other  injections  may  be  tried-,  such  as  so- 
lutions of  tannin,  alum,  red  wine,  and  water,  commencing  with  a  weak 
solution,  and  running  up  the  strength  while  the  effect  is  watched. 

As  soon  as  the  inflammatory  process  has  so  far  subsided  as  to  allow 
the  introduction  of  a  speculum,  any  convenient  instrument  may  be  used 
by  the  aid  of  which  the  walls  of  the  vagina  may  be  thoroughly  inspected 
after  the  canal  has  been  washed,  and  the  eroded  spots  of  congested 
membrane  may  be  directly  touched  with  a  strong  solution  of  tannin  or  a 
moderate  solution  of  nitrate  of  silver.  Such  topical  applications  should 
be  repeated  daily,  the  strength  of  the  solutions  being  graded  according  to 
the  effect.  At  this  time,  also,  advantage  may  be  derived  from  the  use  of 
tampons  of  absorbent  cotton  which  may  be  introduced,  of  small  size, 
through  the  speculum.  Several  small  packages  should  be  tied  up  along  a 
string,  like  a  kite-tail,  to  facilitate  withdrawal,  for  the  purpose  of  absorb- 
ing the  pus  as  it  is  formed,  and  keeping  the  inflamed  surfaces  apart.  The 
various  forms  of  absorbent  cotton  may  be  used  in  this  way — that  prepared 
with  carbolic  or  salicylic  acid,  with  alum,  iron,  sulphate  of  zinc,  etc. — or 
the  physician  may  apply  powders  or  solutions  of  any  strength,  upon  one 
of  these  small  tampons.  By  these  means,  without  discomfort  to  the  pa- 
tient, a  constant  application  of  any  substance  desired  may  be  maintained. 

Finally,  when  the  discharge  has  nearly  ceased,  the  spots  from  which  it 
exudes  must  be  sought  out  by  the  aid  of  the  speculum,  and  treated  by 
gentle  pencilling  with  nitrate  of  silver,  or  by  astringents  directly  applied. 
Cheron  thinks  well  of  the  application  of  pure  glycerine  to  inflamed  sur- 
faces in  the  vagina. 

The  different  forms  of  vaginal  suppository,  found  in  the  shops,  do  not 
yield  as  satisfactory  results  as  might  be  expected  of  them.  They  seem 
appropriate,  but  like  the  urethral  medicated  bougies  for  the  male,  they  do 
not  perform  as  well  as  they  promise. 

The  internal  treatment  of  gonorrhoea  in  the  female  is  mainly  symp- 
tomatic. Food  must  be  light  at  first,  because  the  patient  is  put  upon  her 
back  and  deprived  of  exercise.  Later  the  food  must  be  strengthened  in 
quality.  Laxatives  have  to  be  employed,  and,  finally,  perhaps  tonics  and 
stimulants. 

A  lingering,  chronic  urethritis,  giving  no  symptoms  of  which  the  pa- 
tient is  conscious,  but  yielding  a  drop  of  pus  to  pressure,  upon  the  ure- 
thra from  behind  forward,  in  the  intervals  between  urination,  and  tending 
to  prolong  itself  almost  indefinitely  as  a  chronic  contagious  malady,  is 
spoken  of  by  authors.  As  treatment,  a  mild  solution  of  picric  acid  (one 
grain  to  four  ounces  and  increasing)  may  be  injected  into  the  bladder,  as 
advised  by  Cheron,  and  afterward  slowly  voided  through  the  urethra  by 
the  voluntary  effort  of  the  patient,  or,  what  is  better,  a  solid  pointed 
stick  of  nitrate  of  silver  may  be  rapidly  passed  through  the  urethra  and 
immediately  withdrawn,  the  process  to  be  repeated  once  or  twice,  at  in- 
tervals of  about  a  week. 

The  chronic  discharges  from  the  canal  of  the  cervix  and  from  the 
uterus,  which  are  sometimes  left  behind  by  a  gonorrhoea,  belong  to  the 
domain  of  the  uterine  specialist  and  yield  to  the  same  means  that  are 
used  successfully  to  overcome  other  discharges  due  to  causes  not  in  them- 
selves virulent/" 


GONORRHXEA  IN  THE  FEMALE.  333 

It  has  been  claimed  that  gonorrhoea  in  the  female  is  a  fertile  cause  of 
sterility,  that  it  lingers  indefinitely  in  the  uterine  neck,  so  modifying  the 
secretions  that  the  spermatozoa  are  both  mechanically  impeded  and  chem- 
ically devitalized  before  they  can  reach  the  ovum.  It  does  not  seem  to 
me  that  this  point  is  sufficiently  proved  to  be  accepted.  Gonorrhoea  is 
certainly  very  uncommon  among  respectable  women,  and  particularly 
common,  according  to  rny  experience,  among  respectable  men.  Men  are 
certainly  sometimes  rendered  sterile  by  gonorrhoea,  by  the  mechanism  of 
obliteration  of  the  duct  of  the  testicle  as  already  described.  But  even  in 
men  this  result  is  very  exceptionally  uncommon,  and  in  women  it  seems 
to  me  that  it  must  be  equally  uncommon,  or  even  more  so.  In  prostitutes 
who  have  gonorrhoea,  there  are  other  causes  of  sterility  aside  from  gon- 
orrhoea which  are  capable  of  explaining  the  immunity  from  conception 
possessed  by  many  of  these  women. 


CHAPTER  VII. 

COMPLICATIONS     OF     GONORRHCEA    COMMON    TO     BOTH 

SEXES. 

Gonorrhoeal  Rheumatism. — Time  of  Occurrence,  Cause,  Parts  most  often  Involved. — 
Chronic  Hydarthrosis. — The  Poly-articular  Form. — Neuralgia.  — Bursitis. — Nodes. 
— Treatment. — Gonorrhreal  Rheumatic  Iritis,  Conjunctivitis,  Aquo-capsulitis. — 
Contagious  purulent  Ophthalmia,  its  Symptoms,  Course,  atd  Treatment. 

THERE  is  a  form  of  rheumatism  found  in  connection  with  gonorrhoea, 
having  peculiar  characters,  subacute  in  form,  very  chronic  in  duration, 
and  dependent  upon  the  gonorrhoea  as  a  cause.  How  gonorrhoea  causes 
rheumatism  is  not  known.  It  is  believed  to  be  by  a  process  analogous  to 
a  mild  pyaemia,  but  this  explanation  is  hardly  sufficient.  Women  have 
gonorrhoeal  rheumatism  with  exceptional  rarity,  and  this  has  been  ex- 
plained on  the  ground  that  the  vagina  and  not  the  urethra  is  the  common 
seat  of  gonorrhoea  in  the  female.  This  is  obviously  no  explanation,  but 
simply  the  statement  of  a  fact. 

A  rheumatism,  with  certain  qualities  to  be  shortly  described,  attacks 
certain  patients  when  they  have  gonorrhoea,  and  at  no  other  time.  It 
runs  a  course  peculiar  to  itself,  does  not  yield  to  the  ordinary  remedies 
which  are  effective  against  rheumatism,  and  is  not  attended  by  several  of 
the  phenomena  accompanying  ordinary  rheumatism.  It  alternates  some- 
times with  troubles  in  the  eye  resembling  rheumatic  affections  of  that 
organ,  and  seems  to  be  due  to  an  idiosyncrasy  on  the  part  of  the  patient 
rather  than  any  constitutional  tendency  he  may  have  either  to  rheuma- 
tism or  to  gout.  The  malady  itself,  be  it  sfcid,  resembles  rheumatic  gout 
more  than  it  resembles  either  true  rheumatism  or  true  gout. 

The  time  of  occurrence  of  rheumatic  symptoms  complicating  gonor- 
rhoea is  very  variable.  Fournier  places  the  most  common  period  between 
the  sixth  and  the  fifteenth  days  of  the  discharge.  It  rarely  comes  earlier 
than  these  dates,  but  may  be  found  very  much  later,  in  which  case  its 
advent  is  usually  preceded  by  an  increase  in  the  quantity  and  in  the 
thickness  of  the  discharge.  After  joint  complications  have  set  in,  the  dis- 
charge usually  abates  somewhat,  but  it  does  not  cease,  as  it  does  when 
certain  other  complications  occur,  e.g.,  an  intercurrent  attack  of  epididy- 
mitis. 

The  cause  of  the  malady  is  the  existence  of  gonorrhoea.  Beyond 
this,  nothing  is  necessary.  Cold,  a  wetting,  exposure,  diathesis,  wrench- 
ing a  joint,  privation,  bad  hygiene,  none  of  these  causes  need  be  invoked 
to  explain  it.  The  peculiar  idiosyncrasy,  whatever  that  may  be,  is  all 
that  is  necessary.  Fortunately  few  possess  it. 

The  parts  most  often  involved  are  the  joints.  Then  come  the  sheaths 
of  tendons,  muscles,  the  structures  of  the  eye,  the  bursse  and  the  nerves. 
Cases  of  gonorrhoeal  pericarditis,  endocarditis  and  meningitis  are  also 
on  record. 


COMPLICATIONS  OF  GONORKIKEA  COMMON  TO  BOTH  SEXES.      335 

According  to  Fournier  the  sterno-clavicular  articulation  is  a  very  con- 
stant seat  of  gonorrhoeal  rheumatism,  the  knees  very  often  suffer,  the 
ankle  comes  next,  and  then  the  fingers  and  toes.  The  bursae,  the  tendons, 
and  the  muscles  are  involved  in  an  irregular  manner  in  connection  usu- 
ally with  troubles  in  the  joints  which  overshadow  them  in  importance. 

One  of  the  most  common  forms  assumed  by  this  malady  is  that  of  a 
chronic  hydarthrosis,  most  often  attacking  the  knee-joint.  This  form  is 
generally  mono-articular  and  is  apt  to  relapse  in  the  same  individual  dur- 
ing different  attacks  of  urethral  inflammation.  In  a  case  of  bad  stricture 
under  my  care,  the  stricture  being  in  the  membranous  urethra  and  having 
been  treated  by  perineal  section,  the  patient  during  a  number  of  years 
being  careless  in  his  habits  and  inclined  to  drink,  had  repeated  attacks  of 
urethral  inflammation,  not  by  any  means  always  due  to  venereal  causes. 
With  each  attack  of  suppurative  urethritis  he  suffered  simultaneously 
with  some  form  of  gonorrhceal  rheumatism,  and  among  these  had  three 
or  four  attacks  of  hydarthrosis  of  one  or  both  knees  ;  he  had  also,  at  dif- 
ferent times,  the  ocular,  bursal,  tendinous,  arthritic,  and  muscular  symp- 
toms of  gonorrhceal  rheumatism,  and  rarely  escaped  in  less  than  several 
months  from  any  attack.  My  observations  embrace  a  considerable  num- 
ber of  cases  of  gonorrhceal  rheumatism,  and  among  them  hydarthrosis  of 
the  knee  has  been  very  common.  The  ankle  and  the  elbow  suffer  in  the 
same  way,  but  very  much  less  commonly. 

Taking  the  knee  as  type,  in  a  case  of  hydarthrosis,  the  serous  effu- 
sion may  come  on  almost  without  pain;  perhaps  slowly,  sometimes  very 
quickly.  The  patient  finds  that  he  has  lost  confidence  in  his  knee;  it 
seems  unsteady,  and  perhaps  hurts  him  upon  attempting  to  rise  or  on 
going  upstairs.  With  this  he  is  apt  to  have  other  unimportant  pains  in 
different  parts  of  the  body.  He  now  examines  the  knee  to  find  what  is 
wrong,  and  is  astonished  to  find  the  joint  distended  in  an  oval  way,  man- 
ifestly full  of  fluid. 

Sometimes  the  onset  of  the  joint  inflammation  is  attended  by  consid- 
erable local  pain,  but  there  is  no  fever,  no  redness  of  the  skin,  no  sweat- 
ing, no  excess  of  urates  in  the  urine;  and  after  the  effusion  has  taken 
place  the  pain  moderates  or  disappears  entirely,  except  when  the  joint  is 
moved  or  handled.  The  urethral  discharge  meantime  keeps  on  unabated. 
Other  joints  may  now  become  implicated,  but  the  knee  continues  swollen 
instead  of  getting  well,  as  in  ordinary  rheumatism.  Indeed,  the  joint 
first  attacked  is  generally  the  last  to  get  well,  thus  earning  for  the  mal- 
ady the  title,  mono-articular,  even  where  more  than  one  joint  is  affected. 

The  course  of  this  hydarthrosis  is  often  exceedingly  slow.  Acute  sup- 
puration, although  noted,  has  been  rare.  It  has  been  known  to  prolong  it- 
self for  years,  and  to  degenerate  in  strumous  individuals  into  white  swell- 
ing, and  it  may  go  on  to  an  ultimate  disorganization  of  the  joint,  with 
final  anchylosis. 

The  next  form  of  gonorrhceal  rheumatism  to  be  considered  is  the 
poly-articular  variety.  This  form  is  nearly  as  common  as  the  hydarthro- 
sis, and  sometimes  coincides  with  it.  The  affection  closely  resembles 
rheumatic  gout,  but  it  is  desperately  chronic  in  its  course.  A  patient 
under  my  care  has  had  three  attacks  of  this  form  of  gonorrhceal  rheuma- 
tism, each  one  of  which  lasted  him  in  the  neighborhood  of  eighteen 
months. 

The  acuteness  of  the  symptoms,  in  this  form  of  the  malady,  varies 
greatly.  They  may  be  very  mild,  simply  confined  to  a  little  stiffness  of 
the  joints  upon  moving,  especially  in  the  morning,  or  they  may  go  on  to 


336  THE   VENEREAL    DISEASES. 

the  extent  of  occasioning  very  considerable  spontaneous  pain  in  the  af- 
fected joints,  with  redness  of  the  skin  at  first,  and  many  of  the  features 
possessed  by  joints  becoming  inflamed  in  the  course  of  ordinary  rheu- 
matic gout.  After  some  days,  however,  these  acute  symptoms  become 
subacute,  and  the  malady  assumes  its  customary  march,  which  is  one  of 
tiresome  chronicity.  In  this  form  of  the  disease  it  is  customary  for  sev- 
eral, perhaps  for  many  joints,  to  become  involved  consecutively;  but  the 
trouble  continues  in  the  old  joints,  and  does  not  leave  them  when  new 
joints  suffer,  as  is  so  apt  to  be  the  case  in  common  rheumatism.  One 
or  more  of  the  joints  implicated  in  this  form  of  rheumatism  may  become 
the  seat  of  secondary  hydarthrosis,  a  phenomenon  quite  uncommon  in 
ordinary  rheumatism. 

The  general  symptoms  are  moderate.  The  fever  is  absent  or  not  in- 
tense, and  subsides  quickly.  The  urine  continues  normal,  or  if  charged 
with  urates  is  so  to  a  degree  much  less  marked  than  in  ordinary  rheuma- 
tism. The  sweating,  also,  is  moderate,  or  absent  altogether. 

In  this  form  of  gonorrhceal  rheumatism,  especially  when  the  smaller 
articulations  (fingers  and  toes)  are  the  seat  of  the  malady,  the  periosteal 
and  fibrous  tissues  around  the  joints  seem  to  share  in  the  inflammation, 
and  the  joints  become  swollen -in  a  fusiform  manner,  recalling  certain 
forms  of  rheumatic  gout.  These  deposits  are  very  slow  to  disappear. 
Occasionally  they  leave  distortion  of  the  joint  behind  them,  and,  very 
rarely,  anchylosis. 

Finally,  in  connection  with  this  form  of  rheumatism,  relapsing  attacks 
of  erythema  nodosum  upon  the  lower  extremities  have  been  noted,  rheu- 
matic laryngitis  (Libermann)  and  occasionally  pleuritic,  endocardial,  and 
pericardial  troubles. 

Another  form  assumed  by  gonorrhoeal  rheumatism  is  that  of  pain  and 
inflammation  in  the  muscles,  tendons,  sheaths  of  tendons,  bursae,  and 
nerves.  Such  pains  are  sometimes  very  acute,  they  are  aggravated  by 
motion  and  by  handling  the  parts;  they  are  generally  worse  at  night. 
They  are  chronic  in  their  course  and  apt  to  relapse.  A  number  of 
weeks,  or  even  months,  sometimes  pass  before  they  are  brought  under 
control. 

The  bursae  most  often  implicated  are  the  bursa  under  the  tendo-Achil- 
lis  (the  inflammation  of  which  was  at  one  time  thought  to  be  pathogno- 
monic  of  this  form  of  rheumatism),  the  bursa  under  the  inferior  tuberosity 
of  the  os  calcis,  in  front  of  the  patella  and  behind  the  olecranon.  Other 
bursae  also  occasionally  suffer,  and  sometimes  in  a  very  acute  way.  The 
acute  symptoms,  however,  are  rarely  of  long  duration. 

The  bursae  are  very  rarely  attacked  alone.  Their  inflammation  coin- 
cides most  often  with  the  poly-articular  form  of  gonorrhosal  rheumatism,  and 
furnishes  excellent  corroborative  evidence  as  to  the  nature  of  the  disorder. 

Fournier  has  called  especial  attention  to  a  congestive  and  hyperplastic 
condition  of  the  periosteum,  brought  about  by  gonorrhoeal  rheumatism, 
and  found  more  especially  upon  those  portions  of  bone  which  are  most 
prominent,  nearest  the  surface  of  the  body — most  exposed,  in  a  word. 
Circumscribed  pain,  aggravated  by  pressure,  is  the  symptom  which  calls 
attention  to  these  lesions,  and  examination  reveals  generally  a  localized 
swelling  not  larger  than  an  inch  in  diameter,  often  much  smaller.  The 
tissues  in  such  an  area  are  thickened,  the  skin  over  them  sometimes 
reddened.  Fournier  believes  that  the  pain  sometimes  ascribed  to  the 
affection  of  a  bursa  or  tendon  may  be  due  to  a  deep-seated  periostitis — 
the  pain  under  the  heel,  for  example. 


COMPLICATIONS  OF  GONORRIICEA  COMMON  TO  BOTH  SEXES.      337 

These  periosteal  troubles  are  passing  in  their  nature.  In  a  few  days 
the  pain  disappears,  and  resolution  takes  place.  Occasionally  the  local 
troubles  persist  and  terminate  in  a  local  hard  swelling  attached  to  the 
bone,  which  takes  several  months  to  subside. 

The  neuralgias  most  common  in  connection  with  gonorrhceal  rheuma- 
tism attack  the  lumbar  region,  or  involve  the  anterior  crural  or  the  sciatic 
nerves.  They  are  neither  very  common,  nor  very  important. 

Treatment. — Gonorrhoea!  rheumatism  does  not  yield  readily  to  any 
treatment.  Its  peculiarly  persistent  chronicity  is  one  of  the  features  of 
the  disease.  As  much  rest  as  possible  should  be  granted  to  the  affected 
joints,  but  rest  in  bed  is  out  of  the  question  for  a  malady  which  may 
(though  exceptionally)  last  eighteen  months. 

The  hydrarthrosis  should  be  subjected  first  to  the  action  of  multiple 
vesication.  A  large  number  of  small  blisters,  one  or  two  inches  in  diame- 
ter, may  be  consecutively  applied,  until  the  whole  surface  of  the  joint,  ex- 
cepting the  folds  and  such  portions  as  are  put  on  the  stretch  during  the 
movements  of  the  joint,  has  been  covered.  After  this  the  surface  may 
be  kept  constantly  painted  with  the  strong  tincture  of  iodine  and  accurate 
pressure  methodically  applied,  such,  for  instance,  as  is  obtained  for  the 
knee  by  an  elastic  knee-cap. 

Alkaline  medicines  are  of  little  or  no  value  in  any  of  the  forms  of 
gonorrhoeal  rheumatism,  and  the  same  may  be  said  of  colchicum,  quinine, 
colocynth,  and  other  remedies  used  to  overcome  ordinary  rheumatism. 
There  is  rarely  enough  pain  to  call  for  opium.  Bromide  of  potassium,  in 
large  doses,  is  often  sufficient  to  meet  the  indication  furnished  by  pain,  ex- 
cept in  connection  with  some  of  the  acute  outbursts  of  the  affection,  an 
acute  bursitis,  for  instance.  In  such  cases  a  blister  will  often  serve  as  the 
swiftest  anodyne,  and  has  the  advantage  not  only  of  controlling  the  pain, 
but  also  of  curtailing  the  malady. 

One  remedy,  useful  in  rheumatism,  certainly  retains  some  of  its  power 
in  the  gonorrhoaal  variety.  I  refer  to  salicylate  of  soda.  Doubtless  sali- 
cylic acid  or  other  salicylates  would  do  as  well.  I  have  used  the  salicylate 
of  soda  in  several  cases,  pushing  it  rapidly  to  the  point  of  producing 
either  some  disturbance  of  the  head,  the  stomach,  or  the  intestines,  and 
then  reducing  the  dose;  and  I  have  every  reason  to  be  satisfied  with  the 
result,  which  is  sometimes  unexpectedly  prompt.  It  may  fail  absolutely. 

The  iodide  of  potassium  in  moderate,  continued  doses  (gr.  v. — x. 
three  times  a  day)  seems  also  to  possess  virtue  in  combating  some  of  the 
more  chronic  forms  of  the  malady. 

The  chronic  stages  of  trouble  in  the  joints,  tendons,  and  bursse  are 
best  treated  by  frictions,  massage,  and  all  kinds  of  manipulation,  gentle 
or  severe,  according  to  the  intensity  of  the  symptoms,  and  the  effect  pro- 
duced. Sulphur  baths,  alkaline  baths,  Turkish,  Russian,  turpentine,  find 
electric  baths,  are  also  quite  serviceable  in  these  conditions.  Electricity 
•with  massage  often  gives  great  comfort.  The  continued  current  is 
very  useful,  although  some  patients  declare  that  they  derive  most  benefit 
from  the  induced  current. 

Change  of  air  and  sea-bathing  will  sometimes  effect  a  cure,  in  a  case 
which  drags  along  hopelessly  under  all  methods. 

GONOEEHCEAL   IEITIS. 

During  the  course  of  poly-articular  gonorrhoeal  rheumatism,  or  alter- 
natino-  with  it  during  different  attacks  of  urethral  inflammation,  several 
22 


338  THE    VENEREAL   DISEASES. 

maladies  of  the  eye  have  been  noted,  such  as  are  seen,  also,  sometimes  in 
connection  with  ordinary  chronic  rheumatism  and  rheumatic  gout.  The 
iris,  the  conjunctiva,  and  the  membrane  of  Descemet  are  the  tissues  most 
apt  to  be  involved.  These  ocular  affections  are  in  no  way  due  to  con- 
tagion. The  contact  of  pus  with  the  conjunctiva  produces  a  very  differ- 
ent malady,  one  which  threatens  the  existence  of  the  eye,  and  is  very  apt 
to  lead  to  suppuration  of  the  globe.  On  the  other  hand,  the  rheumatic 
maladies  of  the  eye,  dependent  upon  gonorrhoea  as  a  cause,  are  never  due 
to  contagion,  and  invariably  get  well  without  compromising  either  the 
structure  of  the  eye  or  its  function. 

These  maladies,  therefore,  are  not  clinically  of  much  importance,  and 
their  main  interest  lies  in  the  fact  that  once  a  patient  suffers  from  them 
during  the  course  of  a  gonorrhoea,  he  is  almost  certain,  at  the  time  of  his 
next  urethral  inflammation,  to  have  his  eyes  involved  in  a  similar  manner. 

Symptoms. — In  this  malady  the  cornea  generally  becomes  somewhat 
(perhaps  considerably)  clouded,  particularly  in  its  lower  portions.  The 
cornea  is  apt  to  grow  prominent  from  over-distention  with  fluid  (aquo- 
capsulitis).  The  sight  becomes  imperfect,  objects  growing  misty.  The 
iris,  the  main  seat  of  the  malady,  does  not  show  much  change  in  color. 
The  pupil  may  be  slightly  dilated  and  irregular,  or  normal.  The  move- 
ments of  the  iris  are  abolished  or  quite  sluggish  under  the  action  of  light. 
Adhesions  are  not  common,  although  plastic  exudations  do  occur.  There 
is  generally  mild  lachrymation,  slight  photophobia,  and  uneasiness  rather 
than  pain  in  and  about  the  eye. 

The  conjunctiva  may  be  alone  the  seat  of  an  injection  (Fournier)  in 
the  course  of  gonorrhceal  rheumatism  marked  by  slight  redness  and 
swelling  of  the  conjunctiva,  some  uneasiness  or  perhaps  no  pain  at  all, 
and  a  scanty  muco-purulent  discharge. 

The  course  of  this  iritis  is  generally  rapid,  sometimes  quite  slow. 
Untreated  it  may  result  in  adhesions  of  the  iris,  but  the  milder  cases  get 
well  spontaneously.  Both  eyes  are  apt  to  suffer,  more  often  consecutively 
than  simultaneously.  The  diagnosis  of  the  affection  is  easy.  It  could 
hardly  be  possible  to  confound  it  with  purulent  conjunctivitis  due  to  con- 
tact with  gonorrhceal  pus  on  account  of  the  intensity  of  the  symptoms 
in  the  latter  malady. 

Treatment. — If  the  conjunctiva  alone  is  involved,  it  is  sufficient  to 
wash  the  eye  with  warm  water  containing  a  little  salt,  or  to  use  a  solu- 
tion of  one  grain  of  sulphate  of  zinc  in  the  ounce  of  water,  and  to  shield 
the  eye  from  light.  The  patient  may  go  about  as  usual. 

A  certain  amount  of  aquo-capsulitis  does  not  call  for  any  excessive 
precautions.  A  little  atropine  may  be  used  in  addition  to  the  means 
already  indicated,  and  the  fluid  will  generally  disappear  after  a  few  days. 
If  the  tension  becomes  very  great,  the  anterior  chamber  may  be  tapped, 
and  the  fluid  allowed  to  escape. 

When  the  iris  is  lightly  involved  instillations  of  a  solution  of  atropine 
(gr.  ij.  to  the  3  i.)  should  be  made  daily  into  the  eye,  or  oftener  if  neces- 
sary, to  keep  the  pupil  dilated,  and  the  eye  should  be  carefully  shielded 
from  light.  In  more  severe  cases  inunctions  of  belladonna  ointment  and 
of  oleate  of  morphia  about  the  eye  are  called  for  ;  tonics,  good  diet,  change 
of  air  in  chronic  cases,  and  a  leech  to  the  temple  or  a  blister  behind  the 
ear.  It  is  questionable  whether  the  internal  use  of  mercury  is  of  any 
especial  value  in  this  malady.  Chronic  cases  demand  quinine,  tonics, 
time,  and  what  is  perhaps  best  of  all,  change  of  air. 


COMPLICATIONS  OP  GONORRIKEA  COMMON  TO  BOTH  SEXES.     339 
CONTAGIOUS    PURULENT    OPHTHALMIA. 

This  serious  malady  needs  the  force  of  no  new  illustration  to  testify 
to  its  malignity,  yet  I  may  be  pardoned  for  reporting  a  single  case  to  en- 
force upon  the  physician  the  necessity  of  instructing  the  patient  at  all 
times  in  relation  to  the  virulence  of  his  malady,  and  the  danger  he  runs  of 
losing  his  sight,  should  he  inadvertently  inoculate  his  conjunctiva  with 
the  secretions  from  his  own  urethra. 

A  young  man  passing  through  New  York,  consulted  me  for  a  commen- 
cing gonorrhoea,  his  first  attack.  I  saw  him  but  once  and  gave  him  proper 
instructions.  Possibly,  I  was  not  forcible  enough  in  my  warnings  about 
the  eyes,  but  whatever  the  cause,  it  turned  out  that  upon  the  evening  be- 
fore leaving  town  for  the  country  the  patient  experienced  a  feeling  as  if 
there  were  sand  in  the  eye.  Arrived  at  a  country  town  one  eye  was 
quite  inflamed,  and  the  physician  of  the  place  was  summoned.  This  gen- 
tleman declared  the  attack  to  be  due  to  cold,  and  treated  it  with  mild  eye 
washes,  etc.  The  other  eye  now  took  fire.  Pain  was  intense,  the  dis- 
charge profuse.  The  young  man  was  ashamed  to  acknowledge  that  he 
had  a  gonorrhoea,  and  he  was  lulled  into  security  by  the  assurances  of 
his  physician  that  all  would  go  well.  One  of  the  members  of  the  family, 
however,  wrote  to  me  to  ask  for  what  the  boy  had  consulted  me,  and  to 
inquire  whether  any  bad  result  was  to  be  dreaded  from  the  fierce  inflam- 
mation of  both  eyes  already  several  days  old. 

My  instant  reply  was  that  sight  was  threatened,  and  that  the  best  ocu- 
list within  reach  must  be  summoned.  This  was  done,  but  almost  too  late, 
for  after  a  long  and  painful  illness  this  patient  finally  only  recovered  with 
the  perception  of  the  difference  between  light  and  darkness  and  the  power 
to  distinguish  large  moving  objects  in  a  full  light.  His  distorted  iris  was 
attached  on  either  side  to  a  misshapen  scar  constituting  the  cornea.  The 
beauty  had  gone  out  of  his  eyes  and  almost  their  use  forever. 

Gonorrhoea,  perhaps  more  than  all  maladies,  throws  a  responsibility 
upon  the  surgeon  which  he  cannot  escape.  It  is  his  duty,  as  a  part  of  the 
treatment  of  the  disease,  to  dwell  again  and  again  upon  the  danger  the 
patient  runs  of  contaminating  himself  with  his  own  secretions.  If  the 
patient  has  been  thoroughly  impressed  upon  this  point,  and  then  by  acci- 
dent infects  himself  and  through  shame  fails  to  put  any  new  medical  at- 
tendant upon  the  right  track  as  to  the  cause  of  his  malady,  he  has  him- 
self to  blame  for  the  result  and  cannot  accuse  his  first  physician. 

A  patient  with  gonorrhoea  should  wash  his  hands  each  time  after 
handling  his  penis.  All  wraps  and  articles  contaminated  with  the  pus 
should  be  destroyed.  After  washing  his  hands,  the  water  should  be  in- 
stantly thrown  away,  and  the  towel  used  to  dry  his  hands  upon  should 
not  be  used  for  any  other  purpose.  In  the  same  manner,  when  the  sur- 
geon touches  a  patient's  eyes  which  are  suffering  from  this  virulent  in- 
flammation, he  must  use  all  possible  precautions  not  to  carry  the  contagion 
further,  and  all  dressings,  which  have  been  once  defiled  by  contact  with 
the  poisoned  pus  flowing  from  the  eyes,  must  be  immediately  destroyed. 

Fortunately,  gonorrhceal  ophthalmia  is  rare,  doubtless  due  to  the  fact 
that  the  danger  to  the  eye  of  contact  with  gonorrhceal  pus  is  quite  gen- 
erally understood  among  the  people.  The  disease  is  not  often  double  at 
the  start,  but  it  is  very  apt  to  become  double  during  its  course,  unless 
great  care  be  taken  to  shield  the  well  eye  while  the  other  is  being  treated. 

Symptoms. — Within  a  few  hours  after  contagion  the  eye  feels  dry 
and  itching,  as  if  sand  were  beneath  the  lids.  The  eye  waters  a  little  from 


340  THE    VENEREAL    DISEASES. 

the   start,  and  the  conjunctiva  promptly  becomes  red,  the  lids  slightly 
oedematous.     The  preaural  lymphatic  gland  swells  and  becomes  painful 
to  the  touch. 

The  pain,  swelling,  and  discharge  increase  with  wonderful  rapidity. 
The  upper  lid  swells  so  much  and  so  rapidly  that  it  soon  completely  covers 
the  lower  lid,  and  lies  out  prominently  upon  the  cheek,  red  and  oedema- 
tous. 

The  conjunctiva  beneath  is  the  seat  of  enormous  swelling.  It  becomes 
highly  vascular,  looking  raw,  sometimes  livid  in  color,  raised  into  a  thick 
border  around  the  cornea  (chempsis),  which  lies  at  the  bottom  of  the  cup 
formed  by  the  swollen  conjunctiva,  generally  drowned  in  pus.  A  diph- 
theritic exudation  into  the  substance  of  the  conjunctiva  is  quite  frequent 
in  these  cases.  The  membrane  can  be  seen  but  cannot  be  lifted  from  the 
conjunctiva,  since  the  deposit  is  interstitial  and  not  superficial. 

The  pus,  green  and  thick,  flows  out  abundantly  upon  the  cheek, 
thinned  from  time  to  time  by  a  gush  of  tears,  sometimes  tinged  with  blood. 
The  lids  partly  stick  together  with  the  thick  incrustations  of  matter  which 
incessantly  flow  away.  The  epithelium  upon  the  cheek  becomes  sodden, 
perhaps  soaked  away  by  constant  contact  with  the  acrid  secretions. 

The  cornea  soon  gets  into  difficulty  from  strangulation  by  the  chemo- 
sis.  It  becomes  at  first  troubled,  then  softened  at  the  edge  at  points  un- 
derlying the  swollen  conjunctiva,  and  so  rapidly  do  the  morbid  changes 
occur,  that  within  twenty-four  hours  from  the  commencement  of  the  af- 
fection the  cornea  may  have  ulcerated  to  the  point  of  perforation.  Ab- 
scess may  form  in  the  cornea  and  discharge  externally,  followed  shortly 
by  a  giving  way  in  the  posterior  wall  of  the  abscess,  which  allows  the 
fluid  to  escape  from  the  anterior  chamber  and  the  iris  to  protrude  at  the 
opening.  Again,  the  whole  cornea  may  ulcerate  peripherally  and  drop 
out  like  a  watch-glass,  and  this  may  be  followed  by  an  escape  of  the  crys- 
talline lens  and  suppuration,  with  destruction  of  the  entire  contents  of 
the  globe. 

Meantime,  pain  is  often  most  intense  and  photophobia  extreme.  The 
pain  is  felt  not  only  in  the  eye  but  all  around  it.  There  may  be  little  or 
no  fever  (unless  the  globe  suppurates),  but  profound  depression  of  spirits 
is  the  rule.  A  sense  of  some  impending  catastrophe  seems  to  overwhelm 
the  sufferer. 

Treatment. — When  one  eye  is  found  to  be  the  seat  of  contagious 
purulent  ophthalmia,  it  becomes  the  physician's  duty  immediately  to  pro- 
tect the  other  eye.  This  cannot  be  done  in  any  better  way  than  by  lint 
(scraped),  a  piece  of  bandage,  and  some  collodion.  A  thin  piece  of  gauzy 
material,  cut  round,  is  first  placed  over  the  lid,  then  enough  scraped  lint 
is  placed  upon  it  to  make  a  cushion  and  allow  a  little  pressure  to  be  made 
by  the  final  seal,  which  is  composed  of  several  superposed  layers  of  coarse 
cotton  cloth,  cut  round  and  soaked  in  collodion.  These  last  layers  become 
attached  by  the  collodion  to  the  integument  of  the  upper  lid,  the  nose, 
and  the  cheek,  and  absolutely  shut  out  the  eye  from  the  rest  of  the  world. 
This  bandage  may  be  removed,  after  twenty-four  hours,  in  order  to  be 
certain  that  the  conjunctiva  had  not  been  already  contaminated  before  it 
was  applied.  If  at  such  inspection  the  conjunctiva  is  found  sound,  the 
dressing  may  be  reapplied  with  the  absolute  certainty  that  whatever  hap- 
pens to  the  inflamed  eye,  the  other  will  certainly  be  preserved  sound  for 
the  patient's  future  use. 

The  curative  treatment  of  purulent  contagious  conjunctivitis  rests 
upon  cleanliness,  relief  of  strangulation,  and  arrest  of  suppuration. 


COMPLICATIONS  OF  GONORRHOEA  COMMON  TO  BOTH  SEXES.     341 

Cleanliness  must  be  maintained  through  the  whole  course  of  the  affec- 
tion. Poulticing  is  out  of  the  question,  since  it  retains  the  secretions. 
Frequent  washings  with  cool  water  are  to  be  practised,  and  the  edges 
of  the  lids  left  always  smeared  with  vaseline.  This  prevents  their  stick- 
ing together,  and  the  vaseline  itself  does  not  become  rancid.  The  wash- 
ings should  be  done  with  a  large  camel's-hair  pencil,  or  by  squeezing  water 
from  a  soft  rag,  not  with  a  syringe,  for  fear  of  the  sputtering  which  might 
scatter  some  of  the  infectious  pus  into  the  eyes  of  the  nurse  while  per- 
forming the  dressing.  Anything  that  touches  any  pus  from  the  eye  must 
be  thrown  away  at  once  or  immediately  disinfected  in  a  solution  of  per- 
manganate of  potash,  or  other  equally  good  disinfectant.  These  washings 
may  be  repeated,  with  advantage,  hourly,  or  at  such  intervals  as  may  be 
called  for  by  the  accumulation  of  pus. 

Next  to  cleanliness,  or  perhaps  before  it,  comes  the  necessity  of  keep- 
ing down  pus  formation.  This  is  to  be  effected  by'  local  applications, 
first  of  cold,  second  of  caustics.  Thin  compresses,  soaked  in  iced  water, 
and  constantly  changed,  should  be  applied  to  the  eye.  A  night  nurse, 
as  well  as  a  day  nurse,  is  called  for  to  perform  this  arduous  task.  Every 
few  minutes  these  compresses  must  be  changed,  or  they  heat  up  and  be- 
come poultices — agents  of  mischief.  The  colder  the  eye  is  kept,  the  bet- 
ter, and  the  means  which  can  effect  this  most  continuously  should  be  em- 
ployed. Small  quantities  of  pounded  ice  in  a  condome  have  been  sug- 
gested (Grand),  and  might  serve  well  in  some  cases,  but  after  the  vitality 
of  the  cornea  is  threatened  and  ulceration  has  commenced,  it  is  well  to  be 
prudent  in  the  use  of  ice,  or  to  suspend  it  altogether. 

Among  the  local  applications  used  with  the  view  of  keeping  down  pus 
formation,  the  nitrate  of  silver  in  solution  holds  the  first  rank.  It  is  of 
value  when  the  pus  begins  to  be  freely  formed,  and  the  strength  of  solu- 
tion employed,  as  well  as  the  frequency  of  the  applications,  is  decided  by 
the  violence  of  the  flow  of  pus  and  by  the  effect  of  the  applications  upon 
it.  It  is  best  to  use  the  nitrate  of  silver  in  solution,  on  account  of  the 
difficulty  of  touching  all  parts  of  the  inflamed  conjunctiva  with  the  solid 
stick.  It  is  well  to  employ  two  solutions:  one  quite  mild,  from  gr.  iij.  to 
gr.  vi.  to  the  §  i.  of  water,  to  be  applied  every  two  or  three  hours;  and 
another,  much  stronger,  from  gr.  x.  up  to  3  i-  to  the  3  i.,  to  apply  at  in- 
tervals when  the  secretion  of  pus  becomes  too  considerable  to  be  held  at 
all  in  check  by  the  milder  solution.  The  strength  of  the  caustic  solution 
of  course  must  be  regulated  by  the  effect  upon  the  pus-forming  process. 
If  a  reasonably  mild  solution  will  hold  it  in  check,  so  much  the  better;  if 
not,  recourse  may  be  had  at  each  application,  after  an  interval  of  eight  to 
twelve  hours,  or  longer,  if  the  solution  is  quite  strong,  to  a  solution  of 
greater  strength,  until  the  desired  effect  has  been  attained,  after  which 
the  intervals  between  the  applications  may  be  lengthened,  or  their  strength 
diminished. 

In  making  applications  of  the  nitrate  of  silver  to  the  conjunctiva,  the 
lids  should  be  everted  as  much  as  possible,  and  the  application  made  in 
the  main  upon  the  palpebral  conjunctiva;  that  upon  the  globe  is  of  less 
importance,  and  every  effort  should  be  made  to  avoid  getting  any  of  the 
solution  upon  the  cornea  already  devitalized  by  the  strangulation  of  the 
vessels  supplying  its  nourishment,  and  especially  since  it  may  permanently 
discolor  the  cornea.  The  conjunctival  culs-de-sac  stand  in  especial  need 
of  the  applications,  which  can  hardly  be  made  too  thoroughly  at  these 
points.  After  each  application  of  the  nitrate  of  silver  the  eye  should  be 
freely  brushed  over  with  a  strong  solution  of  common  salt  in  water  to 


342  THE    VENEREAL   DISEASES. 

neutralize  all  excess  of  the  nitrate  of  silver  which  may  remain  in  the  eye. 
Cold  compresses  upon  the  eye  after  each  application  of  caustic  will  help 
to  allay  the  pain. 

When  the  conjunctiva  and  lids  swell  much,  the  eye  suffers  from  tension 
in  two  ways:  by  the  tightness  of  the  tarsal  border  which  irritates  the  eye 
and  prevents  a  free  outflow  of  the  discharges,  and  by  the  chemosis  of  the 
conjunctiva  which  strangulates  the  cornea.  Both  of  these  strangulations 
may,  and  should  be  relieved,  the  first  but  freely  cutting  the  outer  canthus, 
enlarging  the  palpebral  slit,  the  second  by  deep  and  thorough  scarifica- 
tion of  the  chemosed  conjunctiva,  or  even  when  the  chemosis  is  more  solid, 
by  snipping  away  portions  of  the  raised  rim  about  the  cornea  with  scissors 
curved  on  the  flat.  A  number  of  strips  of  conjunctiva,  running  in  rays 
away  from  the  cornea,  may  thus  be  snipped  away,  with  the  result  often 
of  saving  the  cornea,  and  without  leading  to  any  ultimate  damage  when, 
the  eye  gets  well.  Both  scarifications  and  partial  excision  of  the  cornea 
should  be  practised  after,  and  not  before,  a  cauterization. 

The  cornea  requires  especial  attention.  The  cup  at  the  bottom  of 
which  it  lies  should  be  washed  out,  and  the  edge  of  the  cornea  all  around 
under  the  overhanging  chemosed  conjunctiva  should  be  frequently  in- 
spected, to  detect  the  commencement  of  abscess,  or  of  the  ulcerative  pro- 
cess. As  soon  as  rupture  of  the  anterior  chamber  seems  imminent,  the 
escape  of  the  fluid  should  be  anticipated  by  paracentesis  of  the  cornea, 
and  the  incision  should  be  kept  fistulous,  if  possible,  by  the  use  of  a  fine 
probe,  until  the  cornea  is  out  of  danger. 

A  solution  of  atropine  should  be  dropped  into  the  eye  several  times  a 
day  from  the  first.  It  tends  to  diminish  intra-ocular  tension,  to  reduce 
pain,  and  to  keep  the  iris  out  of  harm's  way,  either  from  adhesion  or  from 
prolapsing  into  any  fortuitous  opening  in  the  cornea,  due  to  the  perforation 
of  an  ulcer.  Should  such  prolapses  occur,  any  portion  which  projects  may 
be  cut  away.  Adhesion  of  the  iris  to  the  cornea  at  the  point  of  prolapse 
is  quite  certain  to  take  place,  calling  perhaps  for  iridectomy  when  the 
patient  recovers. 

Something  may  be  done  toward  calming  the  peri-orbital  pains  by  in- 
unctions upon  the  brow  and  temple  of  belladonna  ointment  and  oleate 
of  morphine. 

As  the  eye  begins  to  recover,  it  must  be  shaded  from  the  light  and 
tenderly  nursed  for  a  long  time.  The  lotions  of  nitrate  of  silver  may  be 
gradually  reduced  in  strength,  and  finally  substituted  by  mild  solutions  of 
sulphate  of  zinc,  or  alum,  or  by  simple  salt  in  hot  water.  An  eye  may 
come  out  of  the  contest  much  damaged,  but  yet  capable  of  being  nursed 
up  to  the  point  of  being  of  considerable  use  to  its  possessor.  In  bad  cases 
vision  is  totally  destroyed. 

The  internal  treatment  should  be  supporting  and  tonic  throughout, 
all  the  energy  of  the  treatment  being  devoted  to  the  local  measures. 
Mercury,  up  to  the  point  of  producing  salivation,  has  been  advised  in  bad 
cases  where  there  is  a  diphtheritic  tendency,  but  the  suggestion  by  no 
means  receives  the  uniform  indorsement  of  authorities,  and  is  of  question- 
able propriety,  certainly  so  far  as  regards  a  majority  of  the  cases  seen  in 
cities  where  the  vitality  of  the  individual  is  not  high.  The  malady  itself 
is  unquestionably  very  debilitating,  and  tonics  and  good  food  are  called 
for  more  than  any  other  internal  remedies.  Laxatives  are  usually  re- 
quired, and  a  judicious  use  of  anodynes,  to  insure  sleep  and  control  pain. 


INDEX. 


ABORTION  due  to  syphilis,  228 
Abortive  treatment  of  gonorrhoea,  259 
Albuminuria  due  to  syphilis.  219 
Alopecia  due  to  syphilis,  172 
Amyloid  degeneration  due  to  syphilis,  201 
Aphasia  due  to  syphilis,  212 
Ardor  urinae,  treatment  of,  271 
Arkansas  Hot  Springs,  107 
Arthropathy,  syphilitic.  182 
Arteries,  syphilis  of.  203 

cerebral,  syphilis  of,  206 
Auspitz,  excision  of  chancre,  93 
Auto-inoculat  on  of  chancre,  90 

chancroid,  19 

BALANITIS,  treatment  of,  273 

Blood,  a  vehicle  of  syphilitic  contagium, 

05 

Bone  syphilis  in  inherited  disease.  239 
Bone,  syphilis  of,  183 
Brain,  syphilis  of,  20o 
Bubon  d'emblce,  47 
Bubo,  chancroidal.  45 

treatment  of,  47 
indolent,  4(5 

treatment  of,  49 
how  to  open.  48 
of  syphilis,  95 
virulent,  50 

treatment  of,  52 
Bursitis,  syphilitic,  180 

CANCER  antagonistic  to  syphilis,  63 
Caries  sicca,  185 
Cauterisatio  provocatoria,  78 
Chancre,  auto-  and  hetero-inoculation  of, 
90 

herpetiform,  87 
Hunterian,  87 
mixed,  87 
phagedaena  of,  92 
nipple,  88 
lip,  88 
skin,  88 
urethra,  89 
treatment  of,  92 


Chancroid,  1 

auto-inoculation  of,  18,  28 

value  of.  19 
cicatrix  of,  23 
contagion,  methods  of,  18 
communicability  to  animals,  16 
complications  of,  37 
course  of,  20 
diagnosis  of,  24 
diagnostic  table  of,  25,  97 
duration  of,  23 
ecthymatous,  22 
follicular.  22 
form  of,  21 

hetero-inoculation  of,  22 
how  to  cauterize  a,  31 
inflamed,  37 

treatment  of,  38 
inoculation  of,  18,  20,  28 
inoculability,  4 

in  generations,  19 
nature  of,  2 
number  of,  21 

not  a  modified  syphilitic  sore,  5 
of  anus,  35 
finger,  36 
rectum,  35 
vagina,  36 
vulva,  36 
pathology  of,  15 
prognosis  of,  28 
subjective  symptoms  of,  22 
eub-preputial,  35 
treatment,  radical,  30 
palliative,  33 
preventive,  29 
Chancroidal  bubo,  45 
lymphangitis,  44 
phagedrena,  serpiginous,  39 

sloughing,  38 
Choc-en-retour,  73 
Chordee,  255 

treatment  of,  270 
Colles's  law,  89 
Contagion  in  syphilis,  direct  and  mediate, 

75 
Constitution,  as  influencing  syphilis.  81 


346 


INDEX. 


Copaibal  erythema.  263 
Cord,  spinal,  syphilis  of,  213 
Countenance,  syphilitic.  243 
Cystitis,  gonorrhoeal,  270 

DACTYLITIS,  SYPHILITIC,  175 
Dilatation  of  stricture,  continuous,  315 
Divulsion  of  stricture,  310 
Duration  of  syphilis,  76 

EAR,  syphilis  of,  235 
Ecthyraa,  syphilitic,  145 
Ecthymatous  chancroid,  23 
Epididymitis,  chronic,  288 

gonorrhoeal,  279 

syphilitic,  221 
Epilepsy,  syphilitic,  211 
Erythema,  copaibal,  203 
Encephalitis,  syphilitic.  200 
Excision  of  chancre,  93 
Eye,  syphilis  of,  231 

FF.VER,  SYPHILITIC,  101 
Fever,  urethral,  32  i 
Follicular  chancroid,  22 
Fumigation,  mercurial,  122 

GLANDS,  abdominal,  syphilis  of.  200 

abdominal  lymphatic;,  syphilis  of,  203 

lymphatic,  syphilis  of,  95,  171 
Gleet.  257 
Gonorrhoea,  a  cause  of  sterility,  281 

cause  of,  253 

death  due  to,  276 

injections  in,  265 

in  the  male,  249 
treatment  of.  261 
abortive  treatment  of,  259 
hygienic  treatment  of,  260 
symptoms  of,  253 

female,  328 

symptoms  of,  328 
complications  of,  328,  334 
treatment  of,  329 
Gonorrhoea!  cystitis,  276 

epididymitis,  279 

folliculitis,  275 

ophthalmia,  339 

rheumatism,  334 
Gumma  of  bone,  187 

brain,  206 

fauces,  108 

iris.  232 

liver,  201 

lung.  194 

mouth,  1C8 

penis,  221 

skin,  163 

testicle,  223 

HSART,  syphilis  of,  203 
Hemiplegia,  syphilitic.  210 
Hereditary  syphilis,  237 


Herpetiform  chancre,  87 
Hetero-inoculatiou,  20,  90 
Hot  Springs  of  Arkansas,  107 
Huuterian  chancre,  87 
Hygiene  of  anus  in  syphilis,  113 

genitals,  113 

mouth,  112 

syphilis,  109 

IMPOTENCE,  SYPHILITIC,  225 
Incubation  of  chancroid,  20-28 

syphilis,  85 

second,  100 

Induration,  specific  syphilitic,  91 
Infantile  syphilis,  241 
Inheritance  of  syphilis  through  father,  70 

mother,  (i!> 

Inherited  syphilis,  237 
Injection  of  the  urethra,  265 

vagina,  330 
Inoculation  of  chancroid,  10 

ordinary  pus,  11 

syphilitic  chancre,  13 
Insanity,  syphilitic,  212 
Internal  urethrotomy,  305 
Inunction,  mercurial,  124 
Iodides  and  their  use,  131 

bad  effects  of,  133 

dose  of,  135 
lodism,  134 
Iritis  gonorrhoea],  337 

KERATITIS,  interstitial,  246 
Kidney,  syphilis  of,  219 
Klcbs,  helikomonads,  62 

LARYNGITIS,  SYPHILITIC,  192 
Liver,  amyloid  degeneration  of,  201 

gumma  of,  201 

Locomotor  ataxia,  syphilitic.  215 
Lymphangitis  chancroidal,  44 

syphilitic,  95 

MALIGNANT  SYPHILIS,  100 

Marriage,  the  question  of,  in  pyphilis,  70 

Mastitis,  syphilitic,  230 

Meatotomy,  301 

Mercurial  fumigation,  122 

teeth,  245 

Mercury  a  cause  of  bone  disease,  188 
Mixed  chancre,  87 
Mixed  treatment  of  syphilis,  120,  137 

with  iodides  in  excess.  138 
Mucous  membranes,  syphilis  of,  105 
Mucous  patches,  100 

poisonous  nature  of,  04 

treatment  of,  129 
Muscle,  syphilis  of,  178 

syphilitic  nervous  symptoms  in,  213 
Myositis,  syphilitic,  178 

NAILS,  syphilis  of,  174 
Nervous  system,  syphilia  of.  205 
Nodes,  185 


INDEX. 


347 


OPHTHALMIA,  OONORBIKEAL,  339 
Orchitis,  syphilitic,  222 
Osteocopic  pains,  184 


8,   BYPHILITIC,  206 
Papular  syphilitic,  147 
Paraphymosis,  274 
Paraplegia,  syphilitic,  214 
Pemphigus,  syphilitic,  242 
Penis,  syphilis  of,  220 
Perineal  section  with  guide,  319 

without  guide,  322 
Peritoneum,  syphilis  of,  119 
Phagedaena,  38 

treatment  of,  41 

of  syphilitic  chancre,  92 
Phymosis,  inflammatory  treatment  of,  273 
Pigmentary  syphilide,  152 
Placenta,  syphilitic,  228 
Pleiad  of  syphilis,  95 
Posfcbitis,  inflammatory,  273 
Pregnancy  in  syphilitic  women,  227 
Primary  syphilis,  99 
Pustular  syphilide,  secondary,  150 

tertiary,  161 

RECTUM,  syphilitic  stricture  of,  197 
Reinfectio  syphilitica,  83 
Rheumatism,  gonorrhteal,  334 
Roseola,  145 
Rupia,  160 

SALIVATION,  treatment  of,  126 
Scaly  syphilitic  patches,  167 
Secondary  incubation  of  syphilis,  100 
Signmnd's  treatment  of  syphilis,  106 
Spasmodic  stricture,  290 
Stages  of  syphilis,  98 
Strapping  the  testicle.  287 
Sterility  due  to  gonorrhoea.  278 
Stricture  of  larpe  calibre,  295 

treatment  of,  301 

of  small  calibre,  311 
treatment  of,  314 

resilient,  304 

spasmodic,  290 
Snb-preputial  chancroid,  35 
Syphilide,  cornee,  147 

erythematous,  145 

gummatous,  163 

papular,  147 

pigmentary,  152 

pustular,  secondary,  150 
tertiary,  161 

pustnlo-bulbous,  160 

squatnous,  154 

tubercular.  158 

vesicular,  154 
Syphilides,  145 

general  characters  of,  143 
Syphilis,  53 

abortion  due  to.  228 

a  cause  of  amyloid  degeneration,  201 

course  of,  55 

duration  of,  76 


Syphilis,  impotence  due  to,  225 
incubation  of,  85 
influenced  by  constitution,  81 
inherited,  237 

through  father,  70 
mother,  09 

treatment  of,  246 
in  infant  life,  241 
in  pregnancy,  72 
the  third  generation,  78 
malignant,  100 
marriage  during,  76 
methods  of  contagion,  75 
of  the  aptmeuroses,  180 

arteries,  203 

bones,  183 
in  inherited  disease,  239 

brain,  206 

simulating  sunstroke,  213 

bronchial  tubes,  192 

bur«ae,  180 

cerebral  arteries,  206 

cartilages,  189 

cornea,  231 

ear,  235 

eye,  231 

female  genital  system,  226 

fingers,  175 

foetus,  238 

genito-nririary  system,  219 

glands,  lymphatic,  171 
abdominal,  203 

heart,  203 

intestines,  196 

iris,  231 

joints,  182 

kidney,  219 

larynx,  191 

ligaments,  182 

liver,  200 

lungs,  192 

mammary  glands,  230 

mucous  membranes,  165 
treatment  of,  130 

muscles,  178 

nails,  174 

nervous  system,  205 

nose,  190 

oesophagus,  196 

penis,  220 

peritoneum.  199 

placenta,  228 

rectum,  197 

retina,  233 

respiratory  system,  190 

sheaths  of  tendons,  180 

akin,  142 

special  nerves,  216 

spinal  cord,  213 

spleen,  202 

stomach,  196 

supra-renal  capsules.  203 

sympathetic  nerves,  218 
tendons,  180 

testicles,  221 


348 


INDEX. 


Syphilis  of  the  thymus,  203 

toes,  175 

tongue,  194 

trachea,  192 

vascular  system,  203 

veins,  204 

vitreous  body,  232 
pathology  of,  58 
primary,  99 
prognosis  of,  79 
secondary,  99 
second  attacks  of,  83 
stages  of,  98 
symptoms  of,  103 
tertiary,  100 

transmission  of,  to  animals,  17 
treatment  of,  104 

by  fumigation,  122 
inunction,  124 

hygienic,  109,  113 

local,  128 

mixed,  137 

preventive.  108 

specific,  114 

tonic,  by  mercury,  117 

when  to  commence,  116 

stop,  120 

two  attacks  of,  83 
unity  or  duality  of,  7 
vaccinal,  65 
versus  cancer,  63 
without  chancre,  89 
Syphilitic  albuminuria,  219 
alopecia,  172 
aphasia.  212 
bubo,  95 
cataract,  233 
chancre,  86 

course  of,  89 

diagnostic  tables  of,  25,  97 

excision  of,  93 

induration  of,  90 

treatment  of,  92 
countenance,  242 
cyclitis,  233 
dactylitis,  175 
encephalitis,  206 
epilepsy,  211 
epididymitis,  221 
facial  paralysis,  217 
fever,  101 
hemiplegia,  216 
insanity,  212 
keratitis,  interstitial,  245 


Syphilitic  locomotor  ataxia,  215 

lymphangitis,  95 

optic  neuritis,  233 

orchitis,  222 

pachymeningitis,  206 

paraplegia,  214 

paronychia,  175 

pemphigus,  242 

retinitis  pigmentosa,  233 

teeth,  240 

virus,  61 

in  what  contained,  63 
Syphilization,  19 

TATTOOING  syphilis,  64 

Teal's  method  of  inunction,  125 

Teeth,  syphilitic.  243 

mercurial,  245 
Tenositis,  syphilitic,  180 
Tertiary  syphilides,  180 

syphilis,  100 
Testicle,  syphilis  of,  221 
Thymus,  syphilis  of,  203 
Tonic  treatment  of  syphilis  by  mercury, 

117 
Transmission  of  syphilis  by  milk,  67 

semen,  67 

through  inheritance,  68 

to  third  generation,  73 
Tubercular  syphilide,  158 

UNITY  or  duality  of  syphilis,  7,  Gl 
Urethral  chancre,  89 

fever,  324 
Urethritis  in  the  male,  249 

treatment  of,  260 

in  the  female,  treatment  of,  332 
TJrethrotomy,  external,  with  guide,  319 

without  guide,  322 

internal,  305 

of  deep  urethra,  315 
Urine,  retention  of,  in  gonorrho3a,  272 

VACCINAL,  syphilis.  65 
Vaginitis,  gonorrhoeal,  328 
Vapor  mercurial  bath,  122 

domestic,  123 

Vegetations,  treatment  of,  272 
Veins,  syphilis  of  the,  204 
Vesicular  pyphilide.  154 
Virus  of  syphilis  (unity  or  duality),  7,  61 

ZEISSL-,  treatment  of  syphilis,  106 
Zittman's  decoction,  140 


•ft 

6f 


000  504  062  1 


wciUo 

Khkv 
i860 


Keyes. 

The  venereal  diseases 


CALIFORNIA  COLLEGE  OF  MEDICINE  LIBRARY 

UNIVERSITY  OF  CALIFORNIA,  IRVINE 

IRVINE,  CALIFORNIA  92664 


